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.

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