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Effective Date: 
5/2016

Documents

Instructions

Updated: 1/1988

PURPOSE

To request eligibility information from the household's landlord or apartment manager.

PROCEDURE

When to Prepare

Texas Works staff send this form directly to the landlord when the worker determines the landlord should be contacted.

Number of Copies

An original only.

Transmittal

Send the form with a self-addressed, stamped envelope. File the completed form on the right side of the case folder with the corresponding Form H1010-B, Application for Assistance.

Form Retention

Keep Form H1857 for three years from the month the form is signed by the landlord.

DETAILED INSTRUCTIONS

On the front, enter the landlord's name and address in the window space, the date the form is prepared, and the applicant's name and address. Sign the form.

The office address may be rubber-stamped.

Enter the case name and case number in the spaces provided. The head of household or responsible household member signs and dates the form in the spaces provided giving his permission for release of the requested information.

The landlord completes the rest of the form.

Note: Do not delay certification or take adverse action if the landlord fails to return this form.