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: 7/1994


To request domicile verification from a nonrelative who is familiar with the household's situation.


When to Prepare

Income assistance staff

  • mail this form directly to the nonrelative who is familiar with the TANF household, or
  • provide the client with the form to be completed by the nonrelative of choice who is familiar with the household.

Mail the form to the client to be completed at application, complete reviews, and special reviews.

Number of Copies

An original only.


Mail the form directly to the nonrelative. Include a self-addressed, stamped envelope.

File the completed form on the right side of the casefolder with the corresponding Form H1010-B, Application of Assistance.

Detailed Instructions

On the front of the form, enter the

  • name and address of the nonrelative in the window space;
  • date the form is prepared;
  • caseworker's name;
  • office address and telephone (may be rubber stamped in space provided);
  • applicant's name, case number, and address; and
  • date that the form must be returned.

Page 2 of the form is completed by the nonrelative designated by the client or the income assistance worker.