Form H1028, Employment Verification

Effective Date: 7/1999


English Word: H1028.doc
English PDF: H1028.pdf

Spanish Word: H1028-S.doc
Spanish PDF: H1028-S.pdf


Updated: 1/1988


  • An employer-completed verification of employment, wages, mandatory withholdings, and deductions.
  • A source for documenting earned income and projecting changes in income when other methods are unavailable or insufficient.


When to Prepare

Use Form H1028 when a client cannot furnish sufficient verification of income or mandatory deductions. Staff send the form to the employer or instruct the client to take it to the employer for completion.

Document in the household's case record the date the form is given to the client.

Number of Copies

Give or send the client or employer one copy of Form H1028 with an addressed, stamped envelope.


File the completed form in the case record directly under the applicable worksheet.

Form Retention

Keep Form H1028 for three years from the month the form is signed by the employer.


On the front, enter the employer's name and address in the window space; the date the form is prepared; the employee's name and Social Security number, if available, in the blanks in the first paragraph; any special comments in the space following the second paragraph; and all required information at the bottom.

The office address may be rubber-stamped.

Enter the employed client's name in the space giving his permission for release of the requested information. He signs and dates the form in the spaces provided.

On the back above the chart, enter the month(s) that wage information is needed.

The employer completes the rest of the form. All items are self-explanatory.

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