Downloading a Form to Your Computer

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC application. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 



Updated: 5/2003


To request verification of cash contributions, vendor payments, in-kind assistance, or loans from any source reported by the client in order to correctly determine the type of assistance given and whether the assistance is countable or exempt.


When to Prepare

Use this form to verify contributions, vendor payments, in-kind assistance, or loans made to the household.

Number of Copies

Give or mail the client or the person providing assistance one copy of the form with an addressed, stamped envelope.


File the completed form on the right side of the case folder with the appropriate application or change form.


See the Texas Works Manager's Guide.


Enter the

  • name and address of the person providing the assistance;
  • date, advisor name, office address, and telephone number;
  • case name and case number; and
  • date the information is due.

The person providing assistance to the household completes the remainder of the form.