Form H1134, Help Statement Verification

Instructions

Updated: 11/2021

Purpose

To request verification of cash contributions, vendor payments, in-kind aid, or loans from any source reported by the household. This is to correctly determine the type of help received and if it is countable or exempt.

Procedure

When to Prepare

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

Number of Copies

Give or mail the household or person giving help one copy of the form with an addressed, stamped envelope.

Transmittal

Keep a copy of the completed form with the case record.  

Detailed Instructions

Part I

Case Information — Staff or the person applying for benefits completes Part I.

Case Name — Enter the case name.

Case No. — Enter the case number.

Area Code and Phone No. — Enter a phone number the agency can use if they have questions about the form.

Name of Person Providing Help — Enter the name of the person who gives assistance to the person applying for benefits.

Address of Person Providing Help — Enter the address of the person who is giving help.

Area Code and Phone No. — Enter the phone number of the person who is giving help.

Please Return… — Enter verification due date.

Part II

Help Provided Information — Person who helps the household completes Part II.

Please return…  — Enter the date the information is needed by.

Does this person live with you? — Check “Yes” if the benefits recipient lives with you or “No” if they do not.

Does this person provide cash to anyone in this household? — Check “Yes” if cash is provided to anyone in the household or “No” if you do not.

If “Yes”, who receives the cash? — Specify the recipient of the cash given.

How much do you give them? — Enter the amount of cash given to the household.

How often do you give them cash? — Enter the frequency cash is provided to the household.

When did you begin providing this help? — Enter the date cash assistance began.

Do you expect the money to be repaid? — Check “Yes” if the money is expected to be repaid or “No” if it is not expected to be repaid.

If “Yes”, when? — If “Yes” was answered in the previous question, specify the date on which the money will be repaid.

Do you provide help to the household that is not cash? — Check “Yes” if help other than cash is given to the household or “No” if not.

If “Yes”, check all that apply: — “Shelter”, “Food”, “Personal Items”, “Transportation” or “Other (explain below)” if one or more of the listed is provided. If “Other” is selected, enter details of what other assistance is given to the household in the line below.

Do you pay any of the household’s bills? — Check “Yes” if you pay any of the household bills or “No” if not.

If “Yes”, please specify which bill(s): — If “Yes” was answered in the previous question, specify which household bills you pay for.

If “Yes”, please specify to whom the funds are provided: — If “Yes” was answered in the previous question, specify to whom in the household are the funds given.

Do you plan to continue providing help to this household? — Check “Yes” if you plan to continue giving help to this household or “No” if you do not.

If “Yes”, please specify for how long: — If “Yes” was answered in the previous question, specify for how long you plan on giving help.

If “No”, date of last help: — If “No” was answered in the previous question, specify the date when you last gave aid to the household.

Comments: — Enter any other comments about the help given to the household.

Signature: — Sign and date the form.