173.17 Required Verification for 12-Month Coverage SR 94-04, 04/94 (FAM-A)

The individual must verify household earnings and necessary child care costs for each reporting period. When appropriate, the individual must verify good cause claims for not returning a timely, completed Form 890 or failure to be employed.

Eligibility Factor	Acceptable Proof
Earnings	• A statement from the employer which provides the gross amount and frequency of earnings for each of the 3 months in the report period. • Form 890A, Quarterly Wage Verification, or • Pay stubs or envelopes.
Child care costs	• A statement, receipts, or bills from the child care provider which provides the amount and frequency of child care costs for each of the 3 months of the report period. • A statement from a third-party payor which specifies the amount subject to reimbursement.
Mail Delay	• The postmark on the envelope in which form 890 was returned to the District Office is dated prior to the due date. • Form 890, or the envelope, was date stamped by the District Office on or before the due date.
Emergency	• A signed and dated statement from the parent/caretaker relative describing the emergency and how it specifically resulted in late return of Form 890 or loss of employment.
Illness	• A signed and dated statement from the parent/caretaker relative or a physician describing the duration and nature of the illness and how the illness specifically resulted in late return of Form 890. • A signed and dated statement from the parent/caretaker relative describing the duration and nature of the illness and how the illness specifically resulted in loss of employment.
Involuntary loss of employment	• A signed and dated statement from the employer which indicates that the individual’s termination of employment was involuntary, • A layoff or firing notice, • Receipt of unemployment benefits, • A statement from NHES indicating the parent/caretaker relative is eligible for unemployment benefits, or • A notarized statement from an individual who has direct knowledge of the circumstances which caused the parent/caretaker relative’s involuntary loss of employment.