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Effective Date: 



Updated: 7/1984


To verify income if the household is unable to give suitable documentation.


When to Prepare

The worker prepares Form H1050 if a current award letter is unavailable to verify unearned income, such as government or other pension checks, or if no other verification of earned income is available.

Number of Copies



The worker gives the form to the household to be completed by the household member who cashes the check or checks in question. The worker files the completed form in the case folder with the Form H1801, Food Stamp Worksheet, or Form H1101, TANF Worksheet.

Form Retention

Form H1050 is kept for three years.


The worker completes only client name, case name, case number, worker name, and date.

The remainder of Form H1050 is self-explanatory.