How to Complete the Hawaii DHS 1266: Employer Section, Submission, and Fixing Errors

The Hawaii DHS 1266 form is an employment and payroll verification document that your BESSD eligibility worker uses to confirm your wages during a SNAP, TANF, or General Assistance application or review. You sign a short authorization at the top, your employer completes twelve numbered fields about your job and pay, and the finished form goes back to your processing center by online upload, fax, or mail.¹

Where to Get the Form

The DHS 1266 is a one-page PDF on the Hawaii Department of Human Services BESSD website.¹ In many cases, the eligibility worker mails or faxes it to your employer directly, with the header already filled in: the worker’s name, phone, fax, and unit address appear at the top so the employer knows where to send the completed form.

If you receive a blank copy yourself, check that the worker’s contact information is on the header before you pass it along. You can also pick up a paper copy at any BESSD processing center.

Your Part: The Authorization Block

The only section you personally complete sits near the top of the page. You sign and date a release statement: “I hereby give my permission for the release of information to the Department of Human Services regarding my employment and earnings.”¹ Without your signature, the employer has no obligation to release wage data and the caseworker cannot process the verification.

The header also has fields for your name, Social Security Number, and date of birth. If the worker pre-filled these, read them carefully before handing the form off. A single wrong digit in your SSN can hold up your case.

The form does not have labeled “Part A” and “Part B” sections. It is one page: your authorization at the top, then twelve numbered fields for the employer below.

What Your Employer Fills Out

Everything below your signature is the employer’s responsibility. The twelve fields go well beyond recent pay stubs and build a full picture of your job, compensation, and benefits:

Field 1 — your employment start date, and end date if you no longer work there.
Field 2 — a description of your job type or role.
Field 3 — if you have left, whether you quit, were fired, were laid off, or left for another reason, plus your last day worked.
Field 4 — whether the employer might rehire you, and an approximate date.
Field 5 — whether you are entitled to a pension, with payment dates and amounts.
Field 6 — any sick, vacation, or severance pay issued when you left, with dates and amounts.
Field 7 — cash payments or commissions outside standard payroll, with dates and amounts.
Field 8 — non-cash compensation such as gifts, rewards, or premiums.
Field 9 — whether you applied for or received Workers’ Compensation or Temporary Disability Insurance payments, including the carrier’s name.
Field 10 — health insurance details: who is covered, the plan name and number, the type of coverage, and effective and termination dates.
Field 11 — if no health insurance is available, the reason why.
Field 12 — a payroll table covering recent pay periods: period ending date, date paid, regular and overtime hours, hourly rate, gross pay, tips, advance earned income credit, commissions, medical premium deductions, and year-to-date totals.

The caseworker specifies the date range for Field 12, so the employer should only complete the pay periods requested. After the fields are filled in, the employer’s representative prints a name, title, phone number, and date, then signs a certification that the information is “a true and correct extract from the employment and payroll record(s).”¹ If an answer needs more room, the form says to attach a separate sheet.

Getting Your Employer to Return It Quickly

Most delays start with the form sitting in an HR inbox. Hand it to whoever actually runs payroll rather than your direct supervisor, and say that your benefits depend on a prompt return. If the form stalls, tell your eligibility worker. The worker’s phone and fax are printed on the header for exactly this reason, and a direct call from the state usually gets things moving.

No federal law requires a private employer to complete state benefit-verification forms, but most will. With payroll records open, the form takes a few minutes.

How to Submit the Completed Form

You have three ways to get the finished DHS 1266 back to BESSD.

Online upload. If you have an application in the PAIS portal at pais-benefits.dhs.hawaii.gov, scan or photograph the completed form and upload it through the portal’s document-upload feature.²
Fax. Each processing center has its own fax number; use the one that handles your case. Examples include Kapolei at 692-7783, Waipahu at 675-0038, Maui Public Assistance at 808-984-8333, and Kauai East at 808-241-3187.³
Mail or in-person drop-off. Deliver the form to the processing center nearest you. Some lobby locations have been intermittently closed, so check the BESSD website or call the statewide support line at 1-855-643-1643 before you make a trip.⁴

Your employer can also fax or mail the form straight to the eligibility worker using the contact information in the header. That is often the fastest route because it takes you out of the middle. Confirm with your caseworker which path they prefer, and keep a copy of the completed form for your own records.

What Happens After You Submit

Once the form reaches your processing center, the eligibility worker reviews the wage data alongside the rest of your household income and compares it to the program’s income limits. SNAP limits are set by federal poverty guidelines and are higher in Hawaii than on the mainland.⁵ You will receive a written notice of action in the mail telling you whether your benefits were approved, denied, increased, or reduced, and the effective date of any change.

If the form comes back incomplete, or if the numbers don’t line up with other records the department has, your worker will contact the employer for clarification. Discrepancies can trigger an administrative review, and any overpayment that results from inaccurate reporting has to be paid back.

If the Figures Are Wrong

If your benefits are denied, reduced, or terminated based on the wage information on a DHS 1266, you can request an administrative hearing using form DHS 1461, available on the Department of Human Services website and returned to your processing center by mail or in person.⁶ File as soon as you get the notice of action. Federal SNAP rules generally allow 90 days, but filing before the reduction takes effect gives you the best chance of keeping your current benefit level while the hearing is pending.

At the hearing, you can show that the figures on the form were wrong, that the employer made a mistake, or that the worker miscalculated. Your own pay stubs, bank statements, or a corrected letter from the employer all help. The statewide support line at 1-855-643-1643 can direct you to the right processing center and answer questions about the process.⁴

1
Hawaii Department of Human Services. DHS 1266 Employment Record and Payroll Certification Form
2
Hawaii Department of Human Services. Financial Assistance / SNAP Application
3
Hawaii Department of Human Services. Benefit, Employment and Support Services Division Statewide Processing Centers
4
Hawaii Department of Human Services. SNAP Application, Interview, and Recertification Updates
5
Food and Nutrition Service. SNAP Eligibility
6
Hawaii Department of Human Services. Administrative Hearing Applications