Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  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. 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 provide staff a form to use when a client requests verification to provide a third party that the client conducted business at the local eligibility determination office.


When to Prepare

Use this form to verify that the client conducted business in the local office.

Number of Copies

Give or mail the client one copy of the form.


Give the completed form to the client in person or by mail or fax.


There is no retention requirement for this form.

Detailed Instructions

Staff enters

  • the date, advisor name, office address, and telephone/fax number;
  • the client name, date, and time the client was present in the office; and
  • their phone number, and then prints their name and signs and dates the form.