Case Number: 1050654404

04/23/2024

Need Help? Call 2-1-1

or for out of the state callers,
call 1-877-541-7905
Jose A Martinez Sr Fax: 1-877-447-2839
APT 4207
14332 Montfort DR Mail: Texas Health and Human Services
Dallas TX 75254-8488 Commission
PO Box 149024
Austin Texas 78714-9024
If you have a hearing or speech disability,
call 7-1-1 or any relay service.

To find out if you can get or keep getting benefits, we need more facts from you:
You are getting this packet because either: (1) you applied for benefits, (2) you reported a change to your case, or (3)
we must check your income to see if you can still get benefits.
Inside this packet you will find:
• A list of the items we need from you.
• A pre-paid envelope.

You also might find other forms you can fill out and send to us.

Send us the items by 05/03/2024

If you need help, call us at 2-1-1 or 877-541-7905. After you pick a language, press 2. We can take your call
Monday to Friday, 8 a.m. to 6 p.m. Central Time.
For help or questions about your Lone Star Card account, call 1-800-777-7328 (7EBT).
You still need to send us the items by this due date.

If you don't send us your items by this date,

you might not get benefits or your benefits might end.

There are 4 ways to send us the items we need:

Pick one of these ways to send the items back to us:
• YourTexasBenefits.com: You can upload your items online.

• Your Texas Benefits Mobile App: You can upload your items using the mobile app.
The app is free to download in the Google Play and Apple iTunes stores.

• Mail: Mail this letter and the items we need in the pre-paid envelope that came in this packet.

•
Fax: Fax this letter and the items we need to 1-877-447-2839.

Don't forget:
• Put your case number on everything you send us.
• If you send us a letter or statement showing proof of facts we need, make sure the person who writes it includes:
(1) their name, (2) their address, (3) their phone number, (4) the date they wrote it, and (5) their signature.

Form 1020 Page 1 of 5

12/2022 T-01020-0799092898
 Benefit programs affected and due date:

Program EDG number Due date

For Food Stamp benefits: 718073811 5/22/24

If you're afraid that giving us facts about someone could cause harm (physical or emotional) to you or
your child:
If you're applying for or renewing Medicaid or CHIP benefits, you might not need to give us facts about that
person. You might be able to get the "Family Violence Exemption."
Let us know if you're afraid to give facts about someone:

• Phone: Call 2-1-1 or 1-877-541-7905 (after picking a language, press 2).

• Mail: TEXAS HEALTH AND HUMAN SERVICES COMMISSION,P O Box 149024,

Austin, Texas 78714-9024
• In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 or
1-877-541-7905 (after picking a language, press 1).
• Fax: 1-877-447-2839.

Form 1020 Page 2 of 5

12/2022 T-01020-0799092898
 LIST OF INFORMATION NEEDED AND/OR ACTION REQUIRED:
Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof
Aibil Navarro Food Stamps Provide verification of at least two of the Contact the Employer
following pay amounts. BRIGHTLIGHT Employer.
PRESCHOOL: 01/01/2024 Form 1028 Employment Verification
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer
Aibil Navarro Food Stamps Provide verification of at least two of the Contact the Employer
following pay amounts. BRIGHTLIGHT Employer.
PRESCHOOL: 11/15/2023 Form 1028 Employment Verification
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer
Aibil Navarro Food Stamps Provide verification of at least two of the Contact the Employer
following pay amounts. BRIGHTLIGHT Employer.
PRESCHOOL: 12/01/2023 Form 1028 Employment Verification
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer
Aibil Navarro Food Stamps Provide verification of at least two of the Contact the Employer
following pay amounts. BRIGHTLIGHT Employer.
PRESCHOOL: 12/15/2023 Form 1028 Employment Verification
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer
Jose Martinez Food Stamps Provide verification of at least two of the Contact the Employer
following pay amounts. Max Usa Corp: Employer.
12/01/2023 Form 1028 Employment Verification
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer
Jose Martinez Food Stamps Provide verification of at least two of the Contact the Employer
following pay amounts. Max Usa Corp: Employer.
12/15/2023 Form 1028 Employment Verification
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer
Jose Martinez Food Stamps Provide verification of at least two of the Contact the Employer
following pay amounts. Max Usa Corp: Employer.
12/29/2023 Form 1028 Employment Verification
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer
Aibil Navarro Food Stamps Provide verification of employment history. Employer.
Form 1028 Employment Verification
Form 1020-A Page 3 of 5
12/2022 T-01020-0799092898
 Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof
Form 2583 Choices Information Transmittal
ICFMR staff
Recent checks, stubs, or earnings statements.
Workshop or State School reimbursement officer

Form 1020-A Page 4 of 5

12/2022 T-01020-0799092898
 Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024

Case Number:1050654404

The enclosed Missing Information form (Form 1020) includes a list of documents you need to send to us
so we can determine your eligibility for services.

See page 1 to find out how to send us your forms.

El formulario adjunto de información faltante (Formulario 1020) incluye una lista de documentos que
usted necesita enviarnos para que podamos determiner si usted reúne los requisitos para los servicios.

Vea la página 1 para saber cómo enviarnos sus documentos.

Form 1020B Page 5 of 5

12/2022 T-01020-0799092898
This page intentionally left blank
 Case Number: 1050654404

04/23/2024

Call 2-1-1
Need Help? or for out of the state callers,
call 1-877-541-7905
Jose A Martinez Sr Fax: 1-877-447-2839
APT 4207
14332 Montfort DR Mail: Texas Health and Human Services
Commission
Dallas TX 75254-8488
PO Box 149024
Austin Texas 78714-9024

If you have a hearing or speech disability,

call 7-1-1 or any relay service.

Para saber si puede seguir recibiendo beneficios, necesitamos más información:

Le enviamos este paquete porque: (1) solicitó beneficios, (2) avisó sobre cambios en su caso, o (3) tenemos que revisar su
ingreso para saber si puede continuar recibiendo beneficios.
En este paquete encontrará:
.
.
Una lista de documentos que necesitamos nos envíe
Un sobre pre-pagado.
También podría incluir otros formularios para llenar y enviar.

Envíenos los documentos en o antes del 05/03/2024

Si necesita ayuda llame al 2-1-1 o 1-877-541-7905.
Luego de escoger un idioma, oprima el 2. Podemos atender su llamada de lunes a viernes, de 8 a.m. a 6 p.m., hora
del centro.
Para recibir ayuda o si tiene preguntas sobre su cuenta de Lone Star, llame al 800-777-7328 (7EBT).
Aún tiene que enviarnos los documentos en o antes de la fecha límite.

Si no envía los documentos en o antes de la fecha límite,

no podrá recibir beneficios o sus beneficios terminarán.

Hay 4 maneras para enviarnos lo que necesitamos:

Escoja una de estas opciones para enviarnos los documentos:
. YourTexasBenefits.com: Puede cargar los documentos por Internet.
. Aplicación de Your Texas Benefits: Puede subir sus documentos usando nuestra aplicación
para celular. La aplicación puede bajarse sin costo en Google Play y en iTunes de Apple.
. Por correo: Envíe esta carta y los documentos que necesitamos en el sobre pre-pagado que
le enviamos en este paquete.
. Por fax: Envíe esta carta y los documentos que necesitamos por fax al 1-877-447-2839.

Recuerde:
. Anotar el número de caso en cualquier documento que nos envíe.
. Si va a enviar una carta o declaración que muestre prueba de los datos que necesitamos, asegúrese que la
persona que la escriba incluya: (1) su nombre, (2) dirección, (3) número de teléfono, (4) la fecha en que
escribió la carta y (5) su firma

Forma 1020 Página 1 de 5

12/2022 T-01020-0799092898
 Programas de beneficios que se afectan y las fechas límites:

Programa Número EDG Fecha límite

Para beneficios de Estampillas de Alimentos: 718073811 5/22/24

Si tiene miedo de darnos datos de alguien porque piensa que puede causarles daño (físico o emocional)
a usted o a su niño:
Podría obtener una "Exención de Violencia Doméstica" si solicita o renueva beneficios de Medicaid o de CHIP.
Esto quiere decir que podría no tener que darnos los datos sobre esa persona si tiene miedo de darnos datos
porque piensa que puede causarles daño (físico o emocional) a usted o a su niño.

Avísenos si tiene miedo de darnos datos sobre alguien:

·• Número de teléfono: llame al 2-1-1 o 1-877-541-7905 (después de escoger un idioma, oprima el 2).
• ·Por correo: TEXAS HEALTH AND HUMAN SERVICES COMMISSION, P O Box 149024,
Austin, Texas 78714-9024
• ·En persona: en una oficina de beneficios. Para encontrar una oficina cerca de usted, llame al 2-1-1 o
1-877-541-7905 (después de escoger un idioma, oprima el 1).
• Por fax: 1-877-447-2839.

Forma 1020 Página 2 de 5

12/2022 T-01020-0799092898
 LISTA DE INFORMACIÓN QUE SE NECESITA Y/O ACCIÓN REQUERIDA:
Nombre(s) Programa(s) Información/Acción Solicitada Verificación/Prueba Aceptable

Aibil Navarro Estampillas para Comida Presente un comprobante de al menos dos de Cheques, talonarios o declaraciones de ganancias
los siguientes importes de pago. recientes.
BRIGHTLIGHT PRESCHOOL: 01/01/2024 Contact the Employer
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Empleador.
Formulario 1028 - Verificación del empleador
Aibil Navarro Estampillas para Comida Presente un comprobante de al menos dos de Cheques, talonarios o declaraciones de ganancias
los siguientes importes de pago. recientes.
BRIGHTLIGHT PRESCHOOL: 11/15/2023 Contact the Employer
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Empleador.
Formulario 1028 - Verificación del empleador
Aibil Navarro Estampillas para Comida Presente un comprobante de al menos dos de Cheques, talonarios o declaraciones de ganancias
los siguientes importes de pago. recientes.
BRIGHTLIGHT PRESCHOOL: 12/01/2023 Contact the Employer
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Empleador.
Formulario 1028 - Verificación del empleador
Aibil Navarro Estampillas para Comida Presente un comprobante de al menos dos de Cheques, talonarios o declaraciones de ganancias
los siguientes importes de pago. recientes.
BRIGHTLIGHT PRESCHOOL: 12/15/2023 Contact the Employer
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Empleador.
Formulario 1028 - Verificación del empleador
Jose Martinez Estampillas para Comida Presente un comprobante de al menos dos de Cheques, talonarios o declaraciones de ganancias
los siguientes importes de pago. Max Usa recientes.
Corp: 12/01/2023 Contact the Employer
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Empleador.
Formulario 1028 - Verificación del empleador
Jose Martinez Estampillas para Comida Presente un comprobante de al menos dos de Cheques, talonarios o declaraciones de ganancias
los siguientes importes de pago. Max Usa recientes.

Forma 1020-A Página 3 de 5

12/2022 T-01020-0799092898
 Nombre(s) Programa(s) Información/Acción Solicitada Verificación/Prueba Aceptable
Corp: 12/15/2023 Contact the Employer
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Empleador.
Formulario 1028 - Verificación del empleador
Jose Martinez Estampillas para Comida Presente un comprobante de al menos dos de Cheques, talonarios o declaraciones de ganancias
los siguientes importes de pago. Max Usa recientes.
Corp: 12/29/2023 Contact the Employer
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Empleador.
Formulario 1028 - Verificación del empleador
Aibil Navarro Estampillas para Comida Provea verificación de su historia de trabajo. Cheques, talonarios o declaraciones de ganancias
recientes.
Declaración escrita del oficial de reembolsos del
taller o escuela estatal
Declaración escrita del personal del Centro de
Atención Intermedia para Personas que Tienen
Retraso Mental (ICF-MR)
Empleador.
Formulario 1028 - Verificación del empleador
Formulario 2583 - Transmisión de información de
elecciones

Forma 1020-A Página 4 de 5

12/2022 T-01020-0799092898
 Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024

Case Number:1050654404

The enclosed Missing Information form (Form 1020) includes a list of documents you need to send to us
so we can determine your eligibility for services.

See page 1 to find out how to send us your forms.

El formulario adjunto de información faltante (Formulario 1020) incluye una lista de documentos que
usted necesita enviarnos para que podamos determinar si usted reúne los requisitos para los servicios.

Vea la página 1 para saber cómo enviarnos sus documentos.

Forma 1020 Página 5 de 5

12/2022 T-01020-0799092898
This page intentionally left blank
 TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

Date: 04/23/2024 Need help? Call 2-1-1 or

Case number: 1050654404 1-877-541-7905
Fax: 1-877-447-2839
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 1-800-735-2989.
All numbers are free to call.
JOSE A MARTINEZ SR
APT 4207
14332 MONTFORT DR
DALLAS TX 75254-8488

Note to Jose A Martinez Sr :

This form is for your employer. They need to fill out the form and return it by 05/03/2024 . You must agree to let them give facts about you.
Fill out and sign this agreement:

I, (print your name) Jose A Martinez Sr 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.

Sign here Date

Employer -- your help is needed:

We need proof that the following person is or was your employee.

Employee or former employee Social Security number

Jose A Martinez Sr

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 wotc@twc.state.tx.us.

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 by 05/03/2024
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 1-877-447-2839.

H1028
T-01028-0799092898 03/2021
Page 1
 Texas Health and Human Services Commission
Proof of Employment
To be filled out by the employer Case number : 1050654404
1. Company or employer name: Max Usa Corp
2. Company or employer address - street, city, state, ZIP:
3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP:
5. Is or was this person your employee? Yes No
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."
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply): Full Time Part time Permanent Temporary
10. Average hours per pay period:
11. Rate of pay: $ per: Hour Day Week Month Job

12. How often paid:

Daily Once a week Every 2 weeks

Twice a month Once a month Other:

13. Does or did this person get overtime pay? Yes - often Yes - rarely No - never
14. FICA or FIT withheld? Yes No
15. Is or was this person on leave without pay? Yes No

If yes: Start date of leave: End date of leave:

16. Does this person have a profit sharing or pension plan? Yes No
If yes: What is the current value? $
17. Does your company offer health insurance? Yes No

If yes: This person is: Not enrolled Enrolled with family members Enrolled for self only
If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months? Yes No

If yes: Explain what will change:

19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts):

Date pay Date Actual Gross pay amount Other pay(include tips, EITC Advance Total Pretax
period ended received hours (before taxes taken out) commissions and bonuses) amount Contributions

20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:

21. Does this person still work for you? Yes No

If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $

Employer - read, sign, and date:

I confirm that this information is true and correct to the best of my knowledge:

Employer -sign here Date Title Phone number H1028

03/2021
T-01028-0799092898 Page 2
 TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

Date: 04/23/2024 Need help? Call 2-1-1 or

Case number: 1050654404 1-877-541-7905
Fax: 1-877-447-2839
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 1-800-735-2989.
All numbers are free to call.
JOSE A MARTINEZ SR
APT 4207
14332 MONTFORT DR
DALLAS TX 75254-8488

Note to Jose A Martinez Sr :

This form is for your employer. They need to fill out the form and return it by 05/03/2024 . You must agree to let them give facts about you.
Fill out and sign this agreement:

I, (print your name) Aibil H Navarro Sr 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.

Sign here Date

Employer -- your help is needed:

We need proof that the following person is or was your employee.

Employee or former employee Social Security number

Aibil H Navarro Sr

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 wotc@twc.state.tx.us.

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 by 05/03/2024
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 1-877-447-2839.

H1028
T-01028-0799092898 03/2021
Page 1
 Texas Health and Human Services Commission
Proof of Employment
To be filled out by the employer Case number : 1050654404
1. Company or employer name: BRIGHTLIGHT PRESCHOOL
2. Company or employer address - street, city, state, ZIP:
3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP:
5. Is or was this person your employee? Yes No
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."
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply): Full Time Part time Permanent Temporary
10. Average hours per pay period:
11. Rate of pay: $ per: Hour Day Week Month Job

12. How often paid:

Daily Once a week Every 2 weeks

Twice a month Once a month Other:

13. Does or did this person get overtime pay? Yes - often Yes - rarely No - never
14. FICA or FIT withheld? Yes No
15. Is or was this person on leave without pay? Yes No

If yes: Start date of leave: End date of leave:

16. Does this person have a profit sharing or pension plan? Yes No
If yes: What is the current value? $
17. Does your company offer health insurance? Yes No

If yes: This person is: Not enrolled Enrolled with family members Enrolled for self only
If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months? Yes No

If yes: Explain what will change:

19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts):

Date pay Date Actual Gross pay amount Other pay(include tips, EITC Advance Total Pretax
period ended received hours (before taxes taken out) commissions and bonuses) amount Contributions

20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:

21. Does this person still work for you? Yes No

If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $

Employer - read, sign, and date:

I confirm that this information is true and correct to the best of my knowledge:

Employer -sign here Date Title Phone number H1028

03/2021
T-01028-0799092898 Page 2
 TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

Date: 04/23/2024 Need help? Call 2-1-1 or

Case number: 1050654404 1-877-541-7905
Fax: 1-877-447-2839
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 1-800-735-2989.
All numbers are free to call.
JOSE A MARTINEZ SR
APT 4207
14332 MONTFORT DR
DALLAS TX 75254-8488

Note to Jose A Martinez Sr :

This form is for your employer. They need to fill out the form and return it by 05/03/2024 . You must agree to let them give facts about you.
Fill out and sign this agreement:

I, (print your name) Aibil H Navarro Sr 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.

Sign here Date

Employer -- your help is needed:

We need proof that the following person is or was your employee.

Employee or former employee Social Security number

Aibil H Navarro Sr

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 wotc@twc.state.tx.us.

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 by 05/03/2024
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 1-877-447-2839.

H1028
T-01028-0799092898 03/2021
Page 1
 Texas Health and Human Services Commission
Proof of Employment
To be filled out by the employer Case number : 1050654404
1. Company or employer name: Learning Care Group
2. Company or employer address - street, city, state, ZIP:
3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP:
5. Is or was this person your employee? Yes No
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."
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply): Full Time Part time Permanent Temporary
10. Average hours per pay period:
11. Rate of pay: $ per: Hour Day Week Month Job

12. How often paid:

Daily Once a week Every 2 weeks

Twice a month Once a month Other:

13. Does or did this person get overtime pay? Yes - often Yes - rarely No - never
14. FICA or FIT withheld? Yes No
15. Is or was this person on leave without pay? Yes No

If yes: Start date of leave: End date of leave:

16. Does this person have a profit sharing or pension plan? Yes No
If yes: What is the current value? $
17. Does your company offer health insurance? Yes No

If yes: This person is: Not enrolled Enrolled with family members Enrolled for self only
If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months? Yes No

If yes: Explain what will change:

19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts):

Date pay Date Actual Gross pay amount Other pay(include tips, EITC Advance Total Pretax
period ended received hours (before taxes taken out) commissions and bonuses) amount Contributions

20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:

21. Does this person still work for you? Yes No

If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $

Employer - read, sign, and date:

I confirm that this information is true and correct to the best of my knowledge:

Employer -sign here Date Title Phone number H1028

03/2021
T-01028-0799092898 Page 2