Blank Texas Employment Verification PDF Form Get Texas Employment Verification Here

Blank Texas Employment Verification PDF Form

The Texas Employment Verification form is a document used by employers to confirm the employment status of individuals applying for state benefits. This form requires employers to provide specific details about the employee's work history and compensation. Accurate completion of this form is essential, as it supports the employee's application for assistance.

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The Texas Employment Verification form is an essential document that facilitates the verification of employment for individuals applying for state benefits. This form must be completed by the employer and returned in a timely manner to ensure that the applicant's benefits are processed without delay. It requires the employer to provide key details about the employee, such as their job status, rate of pay, and employment history. Additionally, the form includes a section where the employee must consent to the release of their Social Security number, allowing the Texas Health and Human Services Commission (HHSC) to gather necessary information regarding their employment. Employers are guided through a clear set of instructions to fill out the form accurately, ensuring that all relevant questions are addressed. If any questions do not apply, they can simply mark them as "N/A." The completed form can be returned via mail, fax, or handed directly to the employee, making the process straightforward. By understanding the importance of this form and its requirements, both employers and employees can navigate the verification process with confidence.

Texas Employment Verification Preview

Name and Address
Form H1028 / 07-2022
Date
Need help? Call 2-1-1 or 877-541-7905.
Fax: 877-447-2839
Mail:
Texas Health and Human Services Commission
P O BOX 149027
Austin, Texas 78714-9027
If you are deaf, hard of hearing, or speech
impaired, call 7-1-1 or 800-735-2989. All
numbers are free to call.
Case Name Case No.
This form is for your employer. They need to fill out the form and return it by . You must agree to let them give facts about you.
Fill Out and Sign This Agreement
I,
(print your name) allow HHSC to give my Social Security number (SSN) to the employer listed on this form.
My SSN can be used to get facts about my employment. I also allow the employer listed on this form to give facts asked on this form to HHSC.
Signature Date
Employer – Your Help Is Needed
Employee or Former Employee Social Security No.
We need proof that the following person is or was your employee.
Some employers might get tax refunds or tax credits for hiring people who get certain state benefits.
To learn more, go to TexasWorkforce.org/wotc or email the Texas Workforce Commission at [email protected]
.
Employer please follow these steps.
This person lives in a home in which someone is applying for state benefits. We need to know the amount of money this person makes or
made from this job.
1. Please fill out the “Proof of Employment” form on the next page.
2. If a question doesn't apply, mark it with "N/A."
3. Return the form:
To send this back to us, you can either:
(a) give it to the employee listed above,
(b) mail it in the pre-paid envelope, or (c) fax it to 877-447-2839.
Employment Verification
Form H1028
Page 2 / 07-2022-E
Proof of employment to be filled out by the employer.
Company or Employer
Address (Street, City, State, ZIP code)
Employee Name (as shown on your records) Employee Address (Street, City, State, ZIP Code – as shown on your records)
Is (or was) this person employed by you?
Yes No
If yes, what type of job?
Full Time Part Time Permanent Temporary
If no: Stop here – sign and date the bottom of this form and return it.
If yes: Answer all the questions below. If a question doesn’t apply, write “N/A".
Rate of Pay
Per Hour Per Day Per Week Per Month Per Job
How Often Paid? Average Hours Per Pay Period
Commissions Tips Bonuses
Yes No
Overtime Pay
Frequently Rarely Never
FICA or FIT Withheld
Yes No
Profit Sharing or Pension Plan
Yes No
If yes, current value?
Health insurance available?
Yes No
If yes, employee is:
Not Enrolled Enrolled with Family Member Enrolled for Self Only
Name of Insurance Company
Date Hired Date First Check Received Average Hours Per Week If Employee is or was on Leave Without Pay:
Start Date: End Date:
Do you expect any changes to the above information within the next few months?
Yes No
If yes, explain:
On the chart below, list all wages received by this employee during the month(s) of:
Date Pay
Period Ended
Date Employee
Received Paycheck
Actual
Hours
Gross
Pay
Other Pay*
(tips, commissions, bonuses)
EITC
Advance
Total Pretax
Contributions
* Please explain (in comments section below) when and how often tips, commissions, or bonuses are received.
Comments
If this person is no longer in your employ.
Date Separated Reason for Separation Date Final Check Received Gross Amount of Final Check
Employer – Read, Sign and Date
I confirm that this information is true and correct to the best of my knowledge:
Employer Signature Date Title Area Code and Phone No.
⇓ Texas Employment Verification PDF

Document Specs

Fact Name Description
Purpose The Texas Employment Verification form is used by employers to provide proof of employment for individuals applying for state benefits.
Governing Law This form is governed by the Texas Health and Human Services Commission regulations and related employment laws.
Required Information Employers must fill out details such as employee name, job type, rate of pay, and employment status.
Signature Requirement Both the employee and employer must sign the form to confirm the accuracy of the information provided.
Submission Methods Employers can return the completed form via mail, fax, or by giving it directly to the employee.
Contact Information For assistance, individuals can call 2-1-1 or 877-541-7905, with additional resources available through the Texas Workforce Commission.
Confidentiality Employees must consent to share their Social Security number and employment details with the employer and HHSC.
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Blank Texas Employment Verification PDF Form

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