Get Hi Dhs 1266 2003-2025

The HI DHS 1266 form is designed to request employment and payroll record information for individuals applying for benefits through the Department of Human Services. This guide provides detailed, step-by-step instructions for completing the form online, ensuring accuracy and completeness in your submission.

Follow the steps to accurately complete the HI DHS 1266 form.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out the top section of the form, which requires the date, the subject's Social Security Number (SSN), and the benefit determination (BD) number.
3. Provide the employment details, including starting and ending dates of employment. Enter the start date under 'From:' and the end date under 'To:'.
4. Indicate the nature of employment, describing the individual's job role and responsibilities.
5. State the reason for termination from employment. Options include quit, fired, or laid-off, and enter the last day worked.
6. Answer whether there is a possibility of re-employing the individual in the future. If yes, provide the approximate date.
7. Specify if the individual is entitled to a pension. If yes, include the date and amount of each payment on a separate sheet.
8. Indicate if sick pay, vacation pay, or severance pay was received upon termination. If applicable, provide details on amounts and dates.
9. List any cash payments or commissions received beyond standard salary. Add details for each payment on a separate sheet.
10. Report any gifts, rewards, or premiums received instead of financial payments. Describe the type and date given on a separate sheet.
11. Indicate if the individual received Workmen’s Compensation or Temporary Disability Insurance payments. Provide relevant details or state reasons for ineligibility if not received.
12. State if health insurance is available. If yes, specify the type of coverage and provide details about covered individuals and their insurance plan.
13. If health insurance is not available, provide reasons for ineligibility.
14. Attach payroll records or input wage details for the employment period. Include specifics on payment frequency and amounts.
15. Conclude by certifying the accuracy of the information provided, including the employer representative's signature, job title, and contact phone number.
16. Once all information is entered, you can save the changes, download, print, or share the completed form.

Start filling out your HI DHS 1266 form online today to ensure an accurate and timely submission.