Form H1155, Request for Domicile Verification

Effective Date: 1/1995


PDF: H1155.pdf


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.

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