Table VI - Verification and Interface Match


Effective Date:  September 1, 2018

Previous Table


The eligibility agency must attempt to verify all factors of eligibility electronically before asking client to provide hard copy verifications. 

This table shows the interface matches that are available and gives EXAMPLES of hard copy verifications that may verify the information

you need, although not every example listed will verify all of the information shown under the Eligibility Factors column.  Any other

reasonable method of verification can be used as long as it provides the information needed to determine eligibility.


Eligibility Factor

Interface or Match


U.S. Citizenship;

Age; Identification

Electronic Interface


See Table IV

Alien (INS) Status

Electronic Interface - Social Security screens, Alien Registration

Alien Registration Card

Correspondence from the Department of Homeland Security

Social Security Number;

Social Security Claim #

Electronic Interface

Birth Record




Social Security Card

SSA form 5028 or 2880

Birth Certificate showing SSN applied for

Official Social Security document

Utah Residence; Resident of an Institution

Electronic Interface

New Hire Registry

Prisoner System Information

Current Utah Driver’s license

Employment payroll check stubs

Current UTES registration

House payment receipt

Current rent receipt

Utah telephone book listing (referenced)

Tribal Record correspondence

Children's residence usually follows that of parents

Nursing home resident (unless placed by another state)

Form 131- Affidavit of Intent to Become a Utah Resident; or other statement of intent to remain in Utah.  Duty of Support

Relationship (Including Specified Relative); Paternity

Electronic Interface, Birth Record

Self-declaration of relationship (unless the agency has conflicting information) 

Birth Certificate

Court Order

Marriage Certificate

DWS Form 941 - Acknowledgment of Paternity

“Voluntary Declaration of Paternity” form filed with Vital Statistics

County Records

Adoption placement or finalization forms (placement forms may be used to determine that child is not with birth parents)

Death records

Divorce records

Documents from other state agencies stating verified relationship

Duty of Support


Completed Application for Child Support Enforcement on each non-custodial parent



Self-declaration (unless the agency has conflicting information) 

Current physician's or nurse mid-wife’s statement

Current statement from Planned Parenthood

Statement from a health clinic

School Attendance


DWS form 126

Telephone contact with school

Application for Other Benefits

Electronic Interface - Paris (VA income), Workers Comp, Social Security, Unemployment

Statement from other agency

American Indian/Alaska Native or descendents in the 1st or 2nd degree of a Federally recognized tribe member.


* Copayment exemption requires verification of status after the client has had reasonable time to provide verification.


American Indian/Alaska Native (AI/AN)

  • Tribal Identification/Enrollment Card with number/tribal census document issued by a federally recognized tribe indicating the individual's affiliation with the tribe.

  • Certificate of Degree of Indian or Alaska Native Blood (CDIB) signed by the Bureau of Indian Affairs (BIA), or another document from BIA recognizing the person as American Indian/Alaskan Native.

  • Tribal court documents containing identifying information such as name and the date of birth.

  • Indian Health Services (IHS) document indicating the individual is eligible for IHS services as an American Indian/Alaskan Native.  (Such documents must have identifying information about the individual. IE, name and date of birth.)

AI/AN Descendent

  • Documents of ascendent (parent or grandparent) the verifies status as member of federally recognized AI/AN tribe.

  • Provider document:  Birth certificate, tribal court document or IHS fact sheet showing lineal descent from ascendant to descendant.


Earned Income



Electronic Interface, Wages Work Number

New Hire Registry


Employment payroll check stubs

Employer's wage record

Statement from employer

Self-employment records

Copy of most recent tax return

Training, Work Study


Award letter


Earned income in-kind (food, clothing, free housing, etc.)


Employer's records

Statement from employer

Written agreement

Unearned Income

Social Security Benefits (SSA);  Supplemental Security Income  (SSI); VA Benefits; Retirement; Labor Union Benefits; Pensions; Annuity; Disability Compensation; Scholarships/loans; Tribal Income; Cash gifts and prizes

Electronic Interface, Social Security Screens

SOLQ (does not show correct amount if deductions are being taken out of benefits.  Compare both the BDX and the SOLQ to verify the correct amount is counted.)

Client statement of benefits until information appears on the SDX/BDX

 Award letter

 Legally acceptable copy of check


Bank statement showing direct deposit specifying  source of income

Tribal Records

Unemployment Compensation

Electronic Interface, Unemployment

Statement from DWS

Bank statement showing direct deposit


Alimony and Child Support

Electronic Interface, Recovery Services screens

County Clerk records

Divorce decree or other court order about payments including judgment for past due amounts.

Copies of checks received

Statement from ORS

Dividend and Interest


Bank Statements, dividend letters or statements

Currently posted saving passbook

Current credit union statement

Internet on-line banking

Real Property Sales


Sales Contract


Payment of household

expenses by others


Client's statement

Form 702 - Statement of Contribution

Form 17 - Statement of Head of Household


Health Insurance

Electronic Interface

Receipt for health insurance premiums paid

Insurance records/billing statement

Check stubs/statements showing amount paid by individual

Medicare Part A & B Premium Amounts

Electronic Interface - Social Security screens

Medicare Card

Official document from SSA

Alimony and Child Support Paid Out

Electronic Interface, Recovery Services screens (Unemployment Claim Adjustment Field)

Court order showing alimony or child support owed and copies of checks showing payments made

Income tax records

Medical bills owed


Copies of medical services received and current statement of amount owed

Statement from provider of amount owed


TPL: Auto No Fault, Health (hospital),  Accident, Homeowners



Insurance Card

Written or verbal notice from ORS

Client's statement

Health Insurance Coverage



Insurance Card

Written or verbal notice from ORS

Client's statement