Effective Date: 
7/2004

Documents

Instructions

Updated: 5/2003

PURPOSE

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.

PROCEDURE

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.

Transmittal

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

Retention

See the Texas Works Manager's Guide.

DETAILED INSTRUCTIONS

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.

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