Effective Date: 




Updated: 5/2003



To provide staff a way to verify living arrangements when a client resides with another family or friend.



When to Prepare

Use this form to verify a living arrangement.

Number of Copies

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


Keep the completed form with the appropriate application or change report form.


See the Texas Works Manager's Guide.


Detailed Instructions

Enter the

  • name and address of the person providing the information;
  • date, advisor name, office address, and office telephone;
  • case name and number;
  • date the form is due; and
  • client's name in the space giving his permission for release of the requested information. The client signs and dates the form in the appropriate spaces. The advisor indicates which section(s) are to be completed.

The person the client lives with completes the remainder of the form.

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