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Your Texas Benefits: Getting Started (Your Texas Benefits)

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Your Texas Benefits: Getting Started
SNAP Food Benefits
(This used to be called Food Stamps.)
Helps buy food for good health. Some people
might get help the next work day.
TANF Cash Help
for Families
TANF: Temporary Assistance for Needy
Families
Helps pay for things like food, clothing,
and housing.
• TANF: Helps families with children
age 18 and younger pay for basic needs.
TANF gives monthly cash payments.
• One-Time TANF: Helps families with
children age 18 and younger in crisis.
Crises include losing a job, not finding
a job, losing a home, or a medical
emergency. This help is given only
once every 12 months.
• One-Time TANF Grandparent:
Helps grandparents caring for a
child who gets TANF.
Medicaid and CHIP
Helps with medical bills such as bills for
doctors, hospitals, and medicines.
People who can get health-care benefits are:
• Children age 20 and younger who live
with you.
• Pregnant women.
• Adults who either: (1) are caring for
a child in their home or (2) were in
foster care at age 18 or older.
If you want to apply for Medicaid for the
Elderly and People with Disabilities, you
need a different form. To get that form,
call 2-1-1 (after you pick a language,
press 2).
All phone and fax numbers on this form are
free to call. If you are deaf, hard of hearing,
or speech impaired, you can call any number
by calling 7-1-1 or 1-800-735-2989.
How to Apply
What to do:
1. Fill out this form.
2. Sign and date pages 1 and 18.
3. Send “Items we need.”
See pages C and D.
How to send it:
Mail: HHSC, PO Box 149024,
Austin, TX 78714-9968
Fax: 1-877-447-2839. If your
form is 2-sided, fax both sides.
In person: At a benefits office.
To find one near you, go to
YourTexasBenefits.com or call 2-1-1
(after picking a language, press 1).
YourTexasBenefits.com
On this website you can:
• Apply for benefits.
• Find out if you should
apply for benefits.
• Report changes.
• Upload items we need
from you.
• Renew benefits.
Don’t send this page with your form. Keep for your records. Page A
Texas Health and Human Services Commission (HHSC)
Questions about this form
or about benefits
• Go to YourTexasBenefits.com.
or
• Call 2-1-1 (if you can’t connect,
call 1-877-541-7905).
After you pick a language, press 2 to:
– Ask questions about this form.
– Find where to get help filling out this form.
– Check the status of this form.
– Ask questions about benefit programs.
Report waste, fraud, and abuse
If you think anyone is misusing HHSC
benefits, call 1-800-436-6184.
Helpful Tips
•
There are tips in the left
side of each page. They
can help you save time.
• Sign and date pages
1 and 18.
• Send “Items we need.”
See pages C and D.
These pictures tell you what
sections you need to fill out.
For example, if
you see this:
It means that only people
applying for SNAP food
benefits need to fill out
that section.
How to file a complaint
If you have a complaint, first try talking to your benefits advisor
or their supervisor. If you still need help, call 1-877-787-8999.
Help you can get without filling out this form
Services in your area
Do you need help finding services?
Call 2-1-1 (if you can’t connect,
call 1-877-541-7905).
After you pick a language, press 1.
Texas Workforce Network
Are you looking for work?
You can get help:
• Applying for a job.
• Finding a job.
Call 2-1-1 to find a Texas
Workforce Center.
Family Violence Program
Are you afraid for your children’s or
your safety? You can get help:
• Getting a ride to a safe place.
• Finding shelter, legal help,
and a job.
• Getting counseling.
Call the hotline anytime at
1-800-799-7233 (1-800-799-SAFE).
Adult Education and Family
Literacy Program
Do you want help learning to
read or getting a GED? Do you need
help with job skills? Or learning to
speak English?
Call 1-800-441-7323
(1-800-441-READ).
Women, Infants
and Children program (WIC)
Are you pregnant or a new mother?
You can get help:
• Getting food for you and
your children.
• Getting vaccines.
Call 1-800-942-3678.
Alcohol and Drug Abuse
Prevention Program
Do you or someone you know
want to stop using alcohol or drugs?
You can get help:
• Quitting.
• Dealing with a crisis.
• Keeping others from using
drugs or alcohol.
Call 1-877-966-3784
(1-877-9-NO DRUG).
Health Insurance Premium
Payment Program (HIPP)
Do you need help paying for
your health insurance?
Call 1-800-440-0493.
Or write: Texas Health and Human
Services Commission
TMHP-HIPP, PO Box 201120
Austin, Texas 78720-1120
Important Information for Former
Military Service Members
Women and men who served in
any branch of the United States
Armed Forces, including Army, Navy,
Marines, Air Force, Coast Guard,
Reserves or National Guard may
be eligible for additional benefits
and services. For more information,
please visit the Texas Veterans Portal
at https://veterans.portal.texas.gov.
Family Planning
Do you need help with family planning?
Men and women can get help with:
• Birth control supplies.
• Other health care.
Call 2-1-1 to find a clinic.
Women age 15 to 44 who can’t get
Medicaid or CHIP might be able to
get services in the Healthy Texas
Women program. A parent or legal
guardian must apply for young
women age 15 to 17. To learn more,
go to HealthyTexasWomen.org or
call 1-866-993-9972.
Don’t send this page with your form. Keep for your records. Page B
Items we need from anyone on your case
Look below and on the next page for items we might need from you. If you bring or send copies
of these items with your application, it might help us. If you send any items to us, send only copies.
Keep the originals for your records.
We only need items that apply to anyone on your case. For example, if no one has a bank account,
we do not need bank statements.
If you are applying for
Any Benefit Program
bringing or sending copies of items that apply to anyone on your case might help us review it faster.
• Identity (proof of who you are) – Current driver’s
license or Department of Public Safety ID card.
If a person has the right to act for you (as your
authorized representative), that person also needs
to give proof of identity.
• Immigration status – Resident card (I-551), arrival/
departure form (I-94). Or papers from the U.S.
Citizenship and Immigration Services. We need
copies of the front and back of these forms.
• Legal representative (a person who has the right
to act for you on legal issues) – Power of attorney
papers, guardianship order, court order, or similar
court documents.
• Veterans benefits, workers’ compensation,
or unemployment – Award letter or pay stubs.
• Social Security, Supplemental Security
Income (SSI), or pension benefits – Award letter or
pay stubs.
• Military service – Current Military ID
(Form DD-2), military orders, or separation
papers (Form DD-214).
• Loans and gifts (includes someone paying
bills for you) – Loan agreements or statement from
the person giving you money or paying your bills.
Must show that person’s name, address, phone
number, and signature.
• Residence (proof you live in Texas) – Utility bill,
driver’s license, Texas Department of Public Safety
ID, rent receipt, letter from landlord (can’t be
a relative).
If you are applying for
SNAP food benefits
bringing or sending copies of items that apply to anyone on your case might help us review it faster.
• Proof of income from your job – Last 3 pay stubs
or paychecks, a statement from your employer, or
self-employment records.
• Bank accounts – The most current statement
for all accounts.
• Medical costs – Bills, receipts, or statements from
health-care providers (doctors, hospitals, drug
stores, etc.). These items should show costs you
have now and costs you expect in the future.
• Rent or mortgage costs – Recent checks, check
stubs, or statement from the mortgage bank or
landlord. Renters also need to give the landlord’s
name, address, and phone number.
• Dependent care expenses – Receipts, canceled
checks, or a signed statement from the person
you pay. A signed statement must show when and
how much you pay.
• Child support anyone pays – Court papers that show
what you must pay for child support. For example:
divorce decree, court order, or district clerk record.
• Child support anyone gets – District clerk record.
Or letter from the parent who pays showing how
much, how often and the date it is usually paid.
The letter must have the name, address, phone
number, and signature of the parent who pays.
To get SNAP, a person must be a U.S. citizen or legal resident.
More on the
next page
If you need help getting these items, let us know.
Don’t send this page with your form. Keep for your records. Page C
More items we need from you
If you are applying for
TANF Cash Help for Families
bringing or sending copies of items that apply to anyone on your case might help us review it faster.
• Proof of income from your job – Last 3 pay stubs
or paychecks, a statement from your employer,
or self-employment records.
• Bank accounts – Most current statement for
all accounts.
• Proof a child is related to you – Legal birth,
hospital, or baptismal certificate.
• Citizenship – U.S. passport, Certificate of
Naturalization, U.S. birth certificate (copies of the
front and back), hospital record of birth, or
Medicare card. If you were born in Texas, we might
be able to look up your birth record.
• Child’s vaccines – Vaccine records for each child.
• Proof a child lives with you – A signed statement
from your landlord or a non-relative neighbor that
includes his or her name, address, and phone number.
• Child support anyone pays – Court papers that show
what you must pay for child support. For example: divorce
decree, court order, or district clerk record.
• Child support anyone gets – District clerk record.
Or letter from the parent who pays showing how much,
how often and the date it is usually paid. The letter must
have the name, address, phone number, and signature of
the parent who pays.
• Health insurance – Copy of the front and back
of the insurance card or policy.
If you are applying for
CHIP or Children’s Medicaid
bringing or sending copies of items that apply to anyone on your case might help us review it faster.
• Proof of income from your job – One pay stub or
paycheck from the last 60 days, a statement from
your employer, or self-employment records.
• Medical costs – Bills or statements from
health-care providers (doctors, drug stores, etc.)
from the past 3 months. We only need these items
if you haven’t already paid for these services.
• Citizenship – U.S. passport, Certificate of
Naturalization, U.S. birth certificate (copies of
the front and back), hospital record of birth, or
Medicare card. If you were born in Texas, we might
be able to look up your birth record.
If you are applying for
Medicaid for a Pregnant Woman or an Adult
bringing or sending copies of items that apply to anyone on your case might help us review it faster.
• Proof of income from your job – Last 3 pay
stubs or paychecks, a statement from your
employer, self-employment records, or last year’s
tax return.
• Medical costs – Bills or statements from
health-care providers (doctors, hospitals, drug
stores, etc.) from the past 3 months. We only
need these items if you haven’t already paid
for these services.
• Citizenship – U.S. passport, Certificate of
Naturalization, U.S. birth certificate (copies of
the front and back), hospital record of birth, or
Medicare card. If you were born in Texas, we might
be able to look up your birth record.
If you need help getting these items, let us know.
Don’t send this page with your form. Keep for your records. Page D
H1010
11/2019
Page 1
Your Texas Benefits: Form
Please use dark ink. Please print. If you need more room, add pages.
Fill in the circles (
) like this
If you're applying to get
SNAP food benefits, the
first month's amount will
be based on the date we
get pages 1 and 2.
Other benefits also are
based on when we get
pages 1 and 2.
Your Facts
Mark the benefits anyone on your case is applying for:
SNAP Food
Benefits
TANF Cash Help
for Families
Section A
Medicaid or CHIP:
Children
Adult Caring for a Child
Pregnant Women
Person 1: contact person or head of household
First name
Middle name
Last name
Birth date (month/day/year)
Mailing address
City
Home phone
State
Zip
Cell or daytime phone
Home address
County
Zip
State
City
If you return only
pages 1 and 2
now, you still need
to fill out pages 3
to 18 before you
can get benefits.
You have the right to
file this form
immediately if it has
your name, address,
and signature.
You might be able to get SNAP food benefits the next work day if you:
• Are migrant or seasonal farm worker,
• Have $100 or less in available cash and bank account and expect to earn less than
$150 this month, or
• Have costs for housing or utilities that are more than your cash, bank accounts and the
income you expect for the month.
Answer them for everyone living in your home.
1. Is anyone in the home a migrant worker or seasonal farm worker? ................
Yes No
NoYes
3. Does anyone in the home expect to receive money this
month? (This includes money you get from jobs, child
support, social security and unemployment)....................
NoYes
No
Yes
2. Does anyone in the home have money in the bank or cash?......
4. Does anyone in the home pay costs for housing and utilities?
(This includes rent, mortgage, water, gas, electric, sewage,
trash, phone and property tax).....................................
Sign here (or have someone with the right to act for you sign)
Date
Application for benefits
Texas Health and Human Services Commission
Section B
Food Benefits
This section is
only for people
applying for
SNAP
food benefits.
Find out how to
return your form:
See page 3.
More on page 2
Social Security number
- -
/ /
( )
-
-
( )
Adult not Caring for a Child
Amount
$
Amount
$
Amount
$
H1010
11/2019
Page 2
Pregnant
Women
Is anyone in your home pregnant?.................................................
Section C
Application for benefits
Texas Health and Human Services Commission
NoYes
If yes, who?
/
/
Due date
Number of
babies expected
What is the first and last name of the unborn child's father?
First name
Last name
Section D
Military
Service
This section is
only for people
applying for
health-care
benefits.
This section is
only for people
applying
Medicaid or
CHIP.
Is anyone an active duty member of one of these military forces?
• U.S. Armed Forces
• National Guard
• Reserves
• State Military Forces
NoYes
..........................................
If yes, who?
1.Most people applying for benefits must be interviewed.
We often interview people on the phone.
It helps to know if any of the reasons below make it hard for you to get to a benefits office:
• You live more than 30
miles from the closest
benefits office.
• You can't get a ride.
• The weather is bad.
• You are sick.
• Your work or training
hours don't allow you to
get to a benefits office
when it's open.
• You can't travel because
you are age 60 or older,
or you have a disability.
• You are a victim of
family violence.
• You take care of
someone in your home.
Do any of the reasons above apply to you?
..................
No
Yes
2. If you come to our office, will you need special help or equipment?.....
No
Yes
If yes, what do you need?
3. What language do you want to speak during the interview?
4. Will you need an interpreter? We can get one for you for free........
If yes, mark the one you need:
No
Yes
Spanish
Vietnamese
American Sign Language
Other:
Agency Use Only
Expedite?
Date received:
Date screened:
Case:
Screened by:
Section E
Interview
Help
-
-
Social Security number:
Is this your first pregnancy?..........
No
Yes
Yes
No
H1010
11/2019
Page 3
Your Texas Benefits: Form
Please use dark ink. Please print. If you need more room, add pages.
Fill in the circles (
) like this
Contacting
You
Person 1: Contact Person or Head of Household
Section F
Application for benefits
Texas Health and Human Services Commission
Last name
Middle name
First name
Birth date (month/day/year)
Social Security number
E-mail
Are you applying for benefits for yourself or a child? ........................
No
Yes
If yes, give your facts below:
Person 1
Asian
Section G
Person 1
If you get money from
Social Security or railroad retirement,
list the number you have:
Social Security claim number
Railroad retirement number
Married
Single
Separated
Divorced
Widowed
Live in Texas?
No
Yes
Male Female
Hispanic or Latino?............... NoYes
Mark one or more:
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
White
NoYes
Are you going to school?....
NoYes
If yes, are you going full-time? .....
Are you a U.S. citizen? If no, give facts below. ......................................
NoYes
NoYes
Are you a refugee or legally admitted immigrant? .......................................
/
/
If you have a sponsor, write your sponsor's name
Date you entered the U.S. (month/day/year)
NoYes
Are you registered with the U.S.
Citizenship and Immigration Services?
Immigrant registration number
Return this completed form by fax, mail, or in person:
Fax: 1-877-447-2839
Mail: HHSC, PO Box 149024,
Austin, TX 78714-9968
In person: Call 2-1-1 to find an HHSC benefits office near you.
Mark the benefits
Person 1 is applying for:
SNAP Food Benefits
TANF Cash Help
for Families:
TANF
One-Time TANF
One-Time TANF
Grandparent
Medicaid or CHIP for:
Children
Adult caring for a child
Adult not caring for a
child
Pregnant women
- -
If you are applying for Medicaid or CHIP:
You also must fill out the attached form titled
"Applying for or renewing Medicaid or CHIP"
Optional
Questions
/
/
Plan to stay in Texas?
No
Yes
H1010
11/2019
Page 4
Person 2: adult or child applying, spouse of person applying, or parent living with a child who is a applying
Application for benefits
Texas Health and Human Services Commission
Last name
Middle name
First name
Birth date (month/day/year)
Social Security number
/
/
This person's relationship to you
People
Applying
for Benefits
Section H
If this person gets money from
Social Security or railroad
retirement, list the number here:
-
-
Social Security claim #
Railroad retirement #
NoYes
If yes, is this person going full-time?
NoYes
Is this person going to school?
NoYes
Is this person a refugee or legally admitted immigrant? .................................
NoYes
Is this person a U.S. citizen? If no, give facts below ................................
/
/
Date person entered the U.S. (month/day/year)
If this person has a sponsor, write the sponsor's name.
NoYes
Is this person registered with the U.S.
Citizenship and Immigration Services?...
Immigrant registration number
Person 3: adult or child applying, spouse of person applying, or parent living with a child who is a applying
Last name
Middle name
First name
Birth date (month/day/year)
Social Security number
/
/
This person's relationship to you
If this person gets money from
Social Security or railroad
retirement, list the number here:
-
-
Social Security claim #
Railroad retirement #
NoYes
If yes, is this person going full-time?
NoYes
Is this person going to school?
NoYes
Is this person a refugee or legally admitted immigrant? .................................
NoYes
Is this person a U.S. citizen? If no, give facts below ................................
/
/
Date person entered the U.S. (month/day/year)
If this person has a sponsor, write the sponsor's name.
NoYes
Is this person registered with the U.S.
Citizenship and Immigration Services?...
Immigrant registration number
Mark the benefits
Person 2 is applying for:
SNAP Food Benefits
TANF Cash Help
for Families:
TANF
One-Time TANF
One-Time TANF
Grandparent
Medicaid or CHIP for:
Children
Adult caring for a child
Adult not caring for a
child
Pregnant women
Mark the benefits
Person 3 is applying for:
SNAP Food Benefits
TANF Cash Help
for Families:
TANF
One-Time TANF
One-Time TANF
Grandparent
Medicaid or CHIP for:
Children
Adult caring for a child
Adult not caring for a
child
Pregnant women
Widowed
Separated
Divorced
Single
Married
Optional
Questions
No
Yes
Live in Texas?
No
Yes
Plan to stay in Texas?
Hispanic or Latino?
FemaleMale
Mark one or more:
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
White
Asian
Widowed
Separated
Divorced
Single
Married
Optional
Questions
No
Yes
Live in Texas?
No
Yes
Plan to stay in Texas?
Hispanic or Latino?
FemaleMale
Mark one or more:
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
White
Asian
If you are applying
for Medicaid or
CHIP:
You also must fill out
the attached form
titled
“Applying for
or renewing Medicaid
or CHIP?”
H1010
11/2019
Page 5
Person 4: adult or child applying, spouse of person applying, or parent living with a child who is applying
Application for benefits
Texas Health and Human Services Commission
Last name
Middle name
First name
Birth date (month/day/year)
Social Security number
/
/
This person's relationship to you
People
Applying
for Benefits
If this person gets money from
Social Security or railroad
retirement, list the number here:
-
-
Social Security claim #
Railroad retirement #
NoYes
If yes, is this person going full-time?
No
Yes
Is this person going to school?
NoYes
Is this person a refugee or legally admitted immigrant? ................................
NoYes
Is this person a U.S. citizen? If no, give facts below ................................
/
/
Date person entered the U.S. (month/day/year)
If this person has a sponsor, write the sponsor's name.
NoYes
Is this person registered with the U.S.
Citizenship and Immigration Services?...
Immigrant registration number
Person 5: adult or child applying, spouse of person applying, or parent living with a child who is applying
Last name
Middle name
First name
Birth date (month/day/year)
Social Security number
/
/
This person's relationship to you
If this person gets money from
Social Security or railroad
retirement, list the number here:
-
-
Social Security claim #
Railroad retirement #
NoYes
If yes, is this person going full-time?
NoYes
Is this person going to school?
NoYes
Is this person a refugee or legally admitted immigrant? ................................
NoYes
Is this person a U.S. citizen? If no, give facts below ................................
/
/
Date person entered the U.S. (month/day/year)
If this person has a sponsor, write the sponsor's name.
NoYes
Is this person registered with the U.S.
Citizenship and Immigration Services?...
Immigrant registration number
If more than 5
people are applying
for benefits, add
more pages with the
same facts.
Mark the benefits
Person 4 is applying for:
SNAP Food Benefits
TANF Cash Help
for Families:
TANF
One-Time TANF
One-Time TANF
Grandparent
Medicaid or CHIP for:
Children
Adult caring for a child
Adult not caring for a
child
Pregnant women
Mark the benefits
Person 5 is applying for:
SNAP Food Benefits
TANF Cash Help
for Families:
TANF
One-Time TANF
One-Time TANF
Grandparent
Medicaid or CHIP for:
Children
Adult caring for a child
Adult not caring for a
child
Pregnant women
Section H
Widowed
Separated
Divorced
Single
Married
Optional
Questions
No
Yes
Live in Texas?
No
Yes
Plan to stay in Texas?
Hispanic or Latino?
FemaleMale
Mark one or more:
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
White
Asian
Widowed
Separated
Divorced
Single
Married
Optional
Questions
No
Yes
Live in Texas?
No
Yes
Plan to stay in Texas?
Hispanic or Latino?
FemaleMale
Mark one or more:
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
White
Asian
If you are applying
for Medicaid or
CHIP:
You also must fill out
the attached form
titled
“Applying for
or renewing Medicaid
or CHIP?”
11/2019
Page 6
H1010
1st child's name:
Father's first and last name
Father's phone
City
State Zip
Application for benefits
Texas Health and Human Services Commission
Father's Social Security number
Father's birth date (mm/dd/yyyy)
Father's mailing address
Father is:
Out of home
In home
Deceased
Employer
Mother's birth date (mm/dd/yyyy)
Mother's first and last name
Mother's Social Security number
Mother's maiden name
Zip
State
City
Mother's mailing address
Mother's phone
Employer
Deceased
Out of home In home
Mother is:
Section I
More Facts
About Children
Age 18 or
Younger
Were these parents ever married to each other? .......................
NoYes
2nd child's name:
Father's first and last name
Father's phone
City
State
Zip
Father's Social Security number
Father's birth date (mm/dd/yyyy)
Father's mailing address
-
Father is:
Out of home
In home
Deceased
Employer
Mother's birth date (mm/dd/yyyy)
Mother's first and last name
Mother's Social Security number
Mother's maiden name
Zip
State
City
Mother's mailing address
Mother's phone
Employer
Deceased
Out of home In home
Mother is:
Were these parents ever married to each other? .......................
No
Yes
This section
is only for
children
applying for
TANF.
Time Saving Tip
You only need to give
facts for each father
and mother one time.
If a child has the same
mother or father as
another child, you can
write something like
“same as 1st child”
where the parent's
name would go.
Are you afraid that
giving facts about the
child's other parent
might put you or your
children in danger?
You might not have to
help or cooperate with
the Office of Attorney
General to collect child
or medical support if you
are afraid. You can ask
not to give these facts by:
• Telling your benefits
advisor (or designated
representative) reasons
why this might put
you or your children
in danger.
• Signing the Good
Cause request form.
(Your benefits advisor
has this form.)
-
- -
/
/
/
/
/
/
/
/
FATHER
FATHER
MOTHER
MOTHER
- -
- -
-
( )
-
( )
-
( )
-
( )
3rd child's name:
Father's first and last name
Father's phone
City
State
Zip
Father's Social Security number
Father's birth date (mm/dd/yyyy)
Father's mailing address
Father is:
Out of home
In home
Deceased
Employer
Mother's birth date (mm/dd/yyyy)
Mother's first and last name
Mother's Social Security number
Mother's maiden name
Zip
State
City
Mother's mailing address
Mother's phone
( ) -
Employer
Deceased
Out of home In home
Mother is:
Section I
More Facts
About
Children
Age 18 or
Younger
(continued)
Were these parents ever married to each other? .......................
No
Yes
4th child's name:
Father's first and last name
Father's phone
City
State
Zip
Father's Social Security number
Father's birth date (mm/dd/yyyy)
Father's mailing address
-
Father is:
Out of home
In home
Deceased
Employer
Mother's birth date (mm/dd/yyyy)
Mother's first and last name
Mother's Social Security number
Mother's maiden name
ZipState
City
Mother's mailing address
Mother's phone
( ) -
Employer
Deceased
Out of home In home
Mother is:
Were these parents ever married to each other? .......................
No
Yes
11/2019
Page 7
H1010
If you have more
than 4 children
who are age 18
or younger, add
more pages with
the same facts.
-
-
-
-
-
- -
/
/
/
/
/
/
/
/
FATHERFATHER MOTHERMOTHER
Application for benefits
Texas Health and Human Services Commission
-
( )
-
( )
11/2019
Page 8
H1010
Other people in the home
Application for benefits
Texas Health and Human Services Commission
These people live in my home, but they don't want to apply for benefits.
(Parents living with a child age 18 or younger who is applying or a spouse of a person applying should not
be listed here — they should fill out a box in Section H.)
List the birth date only if the person is your relative.
Section J
Other People
in the Home
Relationship to you
Name
Birth date (if relative)
/
/
/
/
Birth date (if relative)
Relationship to you
Name
/
/
Birth date (if relative)
Relationship to you
Name
Other facts
1. Does anyone have a disability? .............................................................
NoYes
If yes, who?
No
Yes
2. Is anyone getting cash help, food or health-care
benefits from another state? .............................................................
Which state?
If yes, who?
When did that person last get benefits?
Other facts
Section K
-
-
Social Security number:
NoYes
NoYes
4. Is anyone living in a place of care such as:
• A homeless shelter. • A drug treatment center.
• A shelter for battered women. • A group home. .......................
If yes, who?
If yes, who?
3. Has anyone been convicted of a felony for conduct that:
(1) took place after August 22, 1996, and (2) involved illegal drugs? .......
NoYes
5. When people break program rules, they are sometimes "disqualified" from getting benefits.
People who are disqualified are sent a letter and told they can't get TANF cash help
or SNAP food benefits.
Is anyone living with you disqualified from getting cash help or food
benefits anywhere in the United States? .........................................
Answer 3, 4,
and 5 only if
anyone is
applying for
TANF cash help
or SNAP food
benefits.
11/2019
Page 9
H1010
Application for benefits
Texas Health and Human Services Commission
Other health insurance
Section L
Medical
Facts
This section
is only for
people
applying for
TANF, Medicaid
or CHIP.
No
Yes
1. Does anyone get Medicaid, or CHIP? ...............................................................
Name of insured person (first, middle, last)
Insurance company
/
/
/
/
Policy number
Coverage start date
Coverage end date
Type of coverage
Amount you pay each month to cover
your children on this insurance.
Who pays the premium?
Who pays the premium?
Type of coverage
Coverage end date
Coverage start date
Policy number
/
/
/
/
Insurance company
Name of insured person (first, middle, last)
$
$
-
-
Social Security number:
Amount you pay each month to cover
your children on this insurance.
If yes, from which state?
If yes, date coverage ends (if not ending, write “Not ending”):
2. Does anyone get health coverage from one the following?...............................
No
Yes
Medicare
Employer Insurance
TRICARE (don’t check if you
have direct care or Line of Duty)
Peace Corps VA Health-care programs
Other
If yes, give facts below.
Yes
No
Is this COBRA coverage? .....................................................................................
Yes No
Is this a retiree health plan? .................................................................................
Yes No
Is this a limited-benefit plan (like a school accident policy)? .............................
Yes No
Is this a state employee benefit plan? ...................................................................
Yes
No
Is this COBRA coverage? .....................................................................................
Yes No
Is this a retiree health plan? .................................................................................
Yes No
Is this a limited-benefit plan (like a school accident policy)? .............................
Yes No
Is this a state employee benefit plan? ...................................................................
11/2019
Page 10
H1010
Application for benefits
Texas Health and Human Services Commission
Medical
Facts
(continued)
Vehicles
No
Yes
Does anyone own or is anyone paying for a:
• car • truck • boat • motorcycle • other ..........................................
Name of owner (first, middle, last) Year
Name of co-owner if also owned by someone outside the home
Money still owed on vehicle
$
Medical bills from the past 3 months
If anyone on your case can't pay their medical bills, Medicaid might pay them.
No
Yes
If yes, who? (first, middle, last)
• The bills must be for services they got in the past 3 months.
• You need to show proof of money you get (income) for the months they got services.
Does anyone applying for benefits have medical bills for services they got in the past 3
months? ..................................................................................................................
If yes, who? (first, middle, last)
Section L
This section
is only for
people
applying for
TANF, Medicaid,
or CHIP.
If yes, give facts below.
VEHICLE 1
Make / Model
Vehicle is used for a person with a disability.
$
Vehicle is used for a person with a disability.
Name of co-owner if also owned by someone outside the home
Year
Make / Model
Name of owner (first, middle, last)
Money still owed on vehicle
Vehicle is used for a person with a disability.
Name of co-owner if also owned by someone outside the home
Year
Make / Model
Name of owner (first, middle, last)
Money still owed on vehicle
$
VEHICLE 2
VEHICLE 3
Section M
Things
Anyone is
Paying for
or Owns
Skip this
section
if you are
applying
only for
Medicaid or
CHIP.
If you need
more room, add
more pages with
the same facts.
-
-
Social Security number:
11/2019
Page 11
H1010
Application for benefits
Texas Health and Human Services Commission
(continued)
Things anyone is paying for or owns
We need to know about items anyone owns or is paying for, such as:
• cash • bank accounts • homes and other property • insurance policies • stocks
No
Yes
Does anyone own or is anyone paying for these types of items? ...........
If yes, give facts below.
Section M
ITEM 2
ITEM 3
If you need
more room, add
more pages.
Skip this section
if you are
applying
only for
Medicaid or
CHIP.
ITEM 1
Item
Account number
$
Value
Names on account or deeds (include co-owners)
Name and address of bank or business (to contact about the item)
Value
Account number
Item
$
Name and address of bank or business (to contact about the item)
Names on account or deeds (include co-owners)
Name and address of bank or business (to contact about the item)
Names on account or deeds (include co-owners)
Value
Account number
Item
$
Money anyone might get from other programs
NoYes
Name of person waiting for an answer
If yes, mark the program anyone is waiting to hear from.
Social Security (RSDI) Supplemental Security Income (SSI)
Other disability Unemployment compensation benefits
Program name
Is anyone waiting for an answer on an application for one of
the programs listed below? .............................................................
Name of person waiting for an answer
Program name
Money
Coming into
the Home
Things
Anyone is
Paying for
or Owns
Section N
-
-
Social Security number:
11/2019
Page 12
H1010
Application for benefits
Texas Health and Human Services Commission
(continued)
Money from jobs or training
Did anyone get money in the past 3 months from:
(a) working for someone else (b) training, or (c) working for themself?.......
Section N
Name of person who got money
Hours worked
$
before taxes and
deductions are taken
out
Is this person currently working at this job or in training?.............................
Money
Coming into
the Home
If yes, give facts below.
NoYes
JOB 3
Amount paid
Start date
/
/
Last payment date (month/year)
/
How often are you paid?
daily twice a month
once a week once a month
every 2 weeks other:
NoYes
NoYes
Was this person working for themselves? ....................................................
If no, list the person or place that paid the money.
before taxes and
deductions are taken
out
Amount paid
Hours worked
Name of person who got money
Last payment date (month/year)
Start date
If no, list the person or place that paid the money.
No
Yes
Was this person working for themselves? ....................................................
No
Yes
Is this person currently working at this job or in training?.............................
JOB 1
JOB 2
Hours worked
before taxes and
deductions are taken
out
Amount paid
Name of person who got money
Last payment date (month/year)
Start date
How often are you paid?
daily twice a month
once a week once a month
every 2 weeks other:
No
Yes
NoYes
If no, list the person or place that paid the money.
Was this person working for themselves? ....................................................
Is this person currently working at this job or in training?.............................
How often are you paid?
daily twice a month
once a week once a month
every 2 weeks other:
$
$
/
/
/
/
/
/
-
-
Social Security number:
11/2019
Page 13
H1010
Application for benefits
Texas Health and Human Services Commission
(continued)
Other money
Does anyone get, or expect to get, any of the types of money listed below? ...............
Section N
Money
Coming into
the Home
No
Yes
Type of money (item you marked above)
MONEY TYPE 3
Cash or gifts.
Supplemental Security
Income (SSI)
Social Security
Retirement benefits
Veterans benefits
Child support anyone gets
Pensions
Payments after being hurt at
work (workers' compensation).
Payments after losing a job
(unemployment compensation).
Alimony.
Interest or dividends.
Payments from private insurance
Loans paid to anyone
on your case.
Payments to help with utilities.
Farming or fishing
(after expenses paid)
Rent or royalty (after expenses paid)
Other
If anyone gets, or expects to get, any of these types of money, give the facts below.
MONEY TYPE 1
$
Last payment date (month/year)
Amount you get paid
Name of person getting this money (if child support, list child's name)
Person, company, or agency paying the money
How often are you paid?
daily
once a week
every 2 weeks
twice a month
once a month
other:
Person, company, or agency paying the money
Name of person getting this money (if child support, list child's name)
Amount you get paid
Type of money (item you marked above)
MONEY TYPE 2
Person, company, or agency paying the money
Name of person getting this money (if child support, list child's name)
Amount you get paid
Type of money (item you marked above)
Last payment date (month/year)
How often are you paid?
daily
once a week
every 2 weeks
twice a month
once a month
other:
How often are you paid?
daily
once a week
every 2 weeks
twice a month
once a month
other:
How often are you paid?
daily
once a week
every 2 weeks
twice a month
once a month
other:
$
$
/
/
/
Amount you get paid
Type of money (item you marked above)
Last payment date (month/year)
Person, company, or agency paying the money
Name of person getting this money (if child support, list child's name)
/
$
MONEY TYPE 4
Last payment date (month/year)
-
-
Social Security number:
If yes mark other types of money anyone gets or might get soon.
11/2019
Page 14
H1010
Application for benefits
Texas Health and Human Services Commission
Housing costs
1. Does anyone pay any of the costs listed below for the home they are living in?
Housing
Costs
No
Type of cost
Person or company that gets the money (name, address, and phone number)
Amount paid
Who pays the cost?
COST 3
Date last paid
How often you paid?
daily
once a week
every 2 weeks
twice a month
once a month
other:
$
/
This section is
only for people
applying for
SNAP benefits.
If yes, mark the costs
they have and list
the amount:
Rent or home payment $
Tax on home $
Water and sewer $
Electricity $
Natural gas/propane $
Phone $
Home insurance $
Other $
NoYes
3. Does another person not living in the home help anyone on your
Costs to take care of others
Does anyone have costs
to take care of others? No
Yes
Examples:
• Child care costs so someone can work,
look for work, go to training, or go to school.
• Costs for people with disabilities or adults who need
help caring for themselves.
• Child support payments, medical bills, and health
insurance you pay for a child living outside the home.
• Alimony payments.
First name of person who gets care or support
/
For court ordered child support
list child who gets support
(provide copy of court order)
Person or company that gets the money (name, address, and phone number)
/
Date last paid
Amount paid
Who pays the cost?
First name of person who gets care or support
Type of cost
/
$
How often you paid?
daily
once a week
every 2 weeks
twice a month
once a month
other:
How often you paid?
daily
once a week
every 2 weeks
twice a month
once a month
other:
For court ordered child support
list child who gets support
(provide copy of court order)
Person or company that gets the money (name, address, and phone number)
Date last paid
Amount paid
Who pays the cost?
$
First name of person who gets care or support
Type of cost
Costs to
Take Care
of Others
Section P
COST 1
COST 2
/
/
For court ordered child support
list child who gets support
(provide copy of court order)
-
-
Social Security number:
Yes
Section O
2. If you pay rent, what is your landlord’s name and phone number?
Landlord's name
Phone
Or for a home they plan to return to? ........................................................................
case pay for housing costs? .............................................................................
If yes, give facts below.
11/2019
Page 15
H1010
Application for benefits
Texas Health and Human Services Commission
Medical costs
Does anyone age 60 or older, or anyone with a disability,
Medical costs
NoYes
This section is
only for people
applying for
Medicaid,
CHIP, or
SNAP food
benefits.
If yes, mark the type of costs they pay:
People
Helping
You
Section R
Doctor Hospital Medicine Health insurance
No
Yes
Did someone help you fill out this form?..................................................................
People helping you
If yes, tell us about that person:
Name
Relationship or organization Phone
Address
Section Q
-
-
Social Security number:
-
( )
For pregnant individuals only
If you get health benefits from us, your health plan provider or managed care organization may
contact you for things like appointment reminders and information about immunizations or
well-check visits.
You can choose to have them contact you by telephone, text message, or email. Please rank
how you would prefer to be contacted, with 1 being your most preferred.
Preferred Method of Contact by Health Plan Providers
or Managed Organizations
Name
Language you prefer to be contacted in:
Telephone number:
By Telephone
By Text message
By e-mail
(If contacted by cellular telephone, the call may be autodialed or prerecorded, and
your carrier’s usage rates my apply.)
Cellular telephone number:
(Carrier message and data rates may apply.)
E-mail address:
pay medical costs? ..........................................................................
11/2019
Page 16
H1010
Application for benefits
Texas Health and Human Services Commission
Signing up to vote
Applying to register or declining to register to vote will not affect the
amount of assistance that you will be provided by this agency.
No
Yes
If you are not registered to vote where you live now, would
you like to apply to register to vote here today? ............................
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE
DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you would like help in filling
out the voter registration application form, we will help you. The decision whether to
seek or accept help is yours. You may fill out the application form in private. If you
believe that someone has interfered with your right to register or to decline to register to
vote, or your right to choose your own political party or other political preference, you
may file a complaint with the
Elections Division, Secretary of State, PO Box 12060, Austin, TX 78711.
Phone: 1-800-252-8683
Agency Use Only: Voter Registration Status
Agency staff signature
Section S
Signing Up
to Vote
(optional)
-
-
Social Security number:
A Person
Who Can
Act for You
Person who has the right to act for you
If you want, you can give someone the right to act for you (an authorized representative).
That person can:
• Give and get facts for this application.
• Take any action needed for the application process. This includes appealing an HHSC decision.
• Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
• Take any action needed for you to get benefits. This includes reporting changes and renewing benefits.
If you give someone the right to act for you, that person agrees to:
• fulfill all your responsibilities related to Medicaid;
• keep information about you private;
• obey state and federal laws about conflict of interest and keeping information private, including:
• laws that protect information on people who apply for or receive Medicaid
(42 CFR part 431, subpart F);
• laws about the privacy and safety of personally identifiable information (45 CFR §155.260(f)); and
• laws barring the state from paying anyone other than your provider or you for Medicaid services,
except in a few circumstances (42 CFR §447.10).
NoYes
Do you want to give someone the right to act for you -- to be your
authorized representative? ............................................................................
If yes, tell us about that person (the authorized representative) by
filling out Appendix C. It is attached to this form.
Don't forget
to sign
page 19.
Section T
Already registered
Client declined
Agency transmitted
Client to mail
Mailed to client
Other
11/2019
Page 17
H1010
Application for benefits
Texas Health and Human Services Commission
Legal
Information
Section U
Legal information
Your Right to be Treated Fairly
This institution is prohibited from discriminating on the
basis of race, color, national origin, disability, age, sex
and in some cases religion or political beliefs.
The U.S. Department of Agriculture also prohibits
discrimination based on race, color, national origin, sex,
religious creed, disability, age, political beliefs or
reprisal or retaliation for prior civil rights activity in any
program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means
of communication for program information (e.g. Braille,
large print, audiotape, American Sign Language, etc.),
should contact the Agency (State or local) where they
applied for benefits. Individuals who are deaf, hard of
hearing or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made
available in languages other than English.
-
-
Social Security number:
Medicaid and Temporary Assistance for
Needy Families
To file a complaint of discrimination regarding a
program receiving Federal financial assistance through
the U.S. Department of Health and Human Services
(HHS), write: HHS Director, Office for Civil Rights,
Room 515-F, 200 Independence Avenue, S.W.,
Washington, D.C. 20201 or call (202) 619-0403 (voice)
or (800) 537-7697 (TTY).
This institution is an equal opportunity provider.
You also can file a complaint with the Texas Health and
Human Services Commission, Civil Rights Office.
Email HHSCivilRightsOffice@hhsc.state.tx.us, call
1-888-388-6332, fax (512) 438-5885, or write Texas
Health and Human Services Commission, Civil Rights
Office, 701 W. 51st St., MC W206, Austin, Texas
78751.
Citizenship and Immigration Status
You can get benefits for your children who are U.S.
citizens or legal immigrants even if you are not a U.S.
citizen or a legal immigrant. You do not have to give
your citizenship or immigration status to get benefits for
your children. You only have to give the citizenship or
immigration status of people who want benefits. If you
are not a U.S. citizen or a legal immigrant, the only
benefits you might be able to get are emergency
Medicaid services. Getting long-term care (Medicaid for
the Elderly and People with Disabilities) or cash help
(TANF) could affect your immigration status and your
chances of getting a Permanent Resident Card (green
card). Getting other benefits will not affect your
immigration status and your chances of getting a
Permanent Resident Card. You might want to talk to an
agency that helps immigrants with legal questions
before you apply. If you are a refugee or have been
given asylum, getting benefits will not affect your
chances of getting a Permanent Resident Card or
becoming a citizen.
Social Security Numbers
You only need to give the Social Security numbers
(SSNs) for people who want benefits. Giving or
applying for an SSN is voluntary; however, anyone who
doesn’t apply for an SSN or doesn’t give an SSN can’t
get benefits. If you don’t have an SSN, we can help you
apply for one if you are a U.S. citizen or a legal
immigrant. You must be a U.S. citizen or a legal
immigrant to get an SSN. You can get benefits for your
children if they have an SSN and you don’t. We will not
give SSNs to the Bureau of Immigration and Customs
Enforcement. We will use SSNs to check the amount of
money you get (income), if you can get benefits, and
the amount of benefits you can get. (7 C.F.R 273.6 for
food benefits; 45 C.F.R 205.52 for TANF; and 42 C.F.R
435.910 for health care.)
Supplemental Nutrition Assistance
Program (SNAP)
To file a program complaint of discrimination, complete
the USDA Program Discrimination Complaint Form,
(AD-3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html,
and at any USDA office, or write a letter addressed to
USDA and provide in the letter all of the information
requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary
for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov
For any other information dealing with Supplemental
Nutrition Assistance Program (SNAP) issues, persons
should either contact the
USDA SNAP Hotline Number at (800) 221-5689, which
is also in Spanish or call the State Information/Hotline
Numbers (click the link for a listing of hotline numbers by
State); found online at:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
11/2019
Page 18
H1010
Application for benefits
Texas Health and Human Services Commission
HHSC uses facts about people applying for benefits to
decide: (1) who can get benefits, and (2) the amount
of benefits. HHSC checks facts with the federal
Income and Eligibility Verification System. If any
facts don't match, HHSC will check other sources
(banks, employers, etc.). If anyone applying for
benefits has an immigration registration number,
HHSC must check with the U.S. Citizenship and
Immigration Services' (USCIS) system. HHSC
will not give anyone's facts to USCIS.
In most cases, I can see and get facts HHSC has about
me. This includes facts I give HHSC and facts HHSC
gets from other sources (medical records, employment
records, etc.). I might have to pay to get a copy of these
facts. I can ask HHSC to fix anything that is wrong. I do
not have to pay to fix a mistake. To ask for a copy or to
fix a mistake, I can call 2-1-1 or my local HHSC benefits
office.
Keeping My Facts Private
HHSC will keep my facts private if they were collected:
• By HHSC staff or contracted provider staff.
• To find out if I can get state benefits.
HHSC can share facts about me:
• When needed for me to get state health-care benefits.
• With phone and utility companies. They will find out if
my bill amount can be lowered. HHSC will give them
my name, address, and phone number.
All Benefit Programs
Facts HHSC Has About Me
SNAP Food Benefits
Telling the Truth
Anyone who applies for or gets SNAP must:
• Tell the truth.
• Never trade or sell SNAP benefits, Lone
Star Cards, or other devices that allow people
to get SNAP.
• Never use or have Lone Star Cards or other
devices if they don't belong to them.
Anyone who chooses
not to tell the truth might:
• Not get SNAP for a year or more.
• Be fined up to $250,000, jailed up to
20 years, or both.
• Lose income tax refunds.
• Be charged with other crimes.
• Have to repay benefits.
• Never get SNAP again.
The same is true if anyone lets someone else use
their Lone Star Card.
Facts Anyone Tells or Gives HHSC
HHSC uses the facts anyone tells or gives HHSC,
including Social Security numbers to:
• Check if that person can get benefits.
• Check that person's facts with computer
matching programs and credit reporting
agencies.
• Make sure that person is following benefit
program rules.
• Help other agencies check if that person can
get other benefits.
• Recover benefits that person wasn't
supposed to get.
• Share facts about that person: (1) with
other state and federal agencies (for example,
the Texas Workforce Commission, the Social
Security Administration, and the Internal Revenue
Service); (2) with law enforcement officials so they
can find people on that person's benefits case (the
household) who are wanted for fleeing the law;
and (3) with federal, state, and private claims
collecting agencies for food benefit overpayment
claims collection action.
(Food and Nutrition Act of 2008,
as amended, 7 U.S.C. 2011-2036.)
TANF Cash Help for Families
Child Support or Alimony
I agree to:
• Let the state keep any child support or alimony
money owed to anyone during the time they
get TANF.
• Let the state keep this money after TANF benefits
end, if the TANF amount anyone got still needs to
be paid off.
• Tell HHSC about money anyone gets.
• Work with HHSC to get this money; if I don't, I am
breaking the law.
The state will keep only the amount allowed by law.
If I Give False Information
If I choose not to tell the truth, I might:
• Be charged with and punished for a crime.
(This could include going to prison for up to 10
years or community supervision.)
• Have to repay benefits.
• Never get TANF again.
Statement of
Understanding
Read Section W
before signing
page 19.
More on next page
-
-
Social Security number:
Section V
11/2019
Page 19
H1010
Application for benefits
Texas Health and Human Services Commission
Statement of
Understanding
Section W
By signing below, I agree:
• To let HHSC and other state, federal, and local agencies check, share, and get facts about anyone on my benefits case (the household).
• To let other people, businesses, and organizations share facts they have about anyone on my benefits case (the household) with HHSC.
• The facts to be checked and shared include anything that helps decide: (1) who can get benefits, and (2) the amount of benefits.
My Answers Are True
I certify under penalty of perjury that the information I have provided on this
application is true and complete to the best of my knowledge. If it is not,
I may be subject to criminal prosecution.
Sign here
Printed name of witness
/ /
//
//
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Phone
Did you...
1. Sign and date
page 1 (if you have
not already sent it in).
2. Include the "items
we need" listed in
the cover section.
3. Sign and date this
page.
Person applying on their authorized representative
If I don't help the state, my child can get Medicaid,
but I might not.
- Identify who the child's other parent is.
- Allow the state to keep any medical support
payments.
• I know I will be asked to cooperate with the
agency that collects medical support from an
absent parent. If I think that cooperating to collect
medical support will harm me or my children, I can
tell HHSC and I may not have to cooperate.
If I get Medicaid, HHSC will keep medical service
payments I can get from other sources, such as:
• My health insurance.
• Money I got because of injuries.
• Money collected for me or my children by the
Office of Attorney General.
I must tell HHSC about these sources. If I don't, I
am breaking the law.
HHSC will only keep the amount of medical support
and service payments allowed by law. I will work
with HHSC to get these funds.
Medicaid
If I Give False Information
If I choose not to tell the truth, I might:
• Be charged with a crime.
• Have to repay benefits.
The same is true if I let someone else use my
medical card or Medicaid ID.
Giving Out Facts About Me
I agree to let Medicaid health care providers
(doctors, drug stores, hospitals, etc.) give out
any facts about me to HHSC. This will allow the
providers to be paid by Medicaid.
Medical and Child Support Payments
Depending on my benefits case, the Attorney
General (the state) might check that I am getting
the right amount of child or medical support
payments
and coverage.
• If only my child gets Medicaid, I can decide
if I want the state to help get any payments
and coverage we should get, but don't get
right now.
• If my child and I both get Medicaid, I must:
- Help the state get any payments and
coverage we should get, but don't right now.
-
-
Social Security number:
-
( )
Sign here to show your agree:
Parent, guardian, or power of attorney for the person applying:
Sign here (you must give proof of this right)
Witness (only needed if anyone above signed with an "X" or other mark).
Sign here
Ready to send this form to us? See “How to send it” at the bottom of page A.
Addendum A . H1010-M
11/2019
Page 1-A
Applying for or renewing
Medicaid or CHIP?
If yes, you must fill out this form.
Each person listed in Section H of the Your Texas Benefits application needs to answer the questions
below (Section 1). The people who should be included in Section H and who should answer the
questions below are:
Section 1
Application for benefits
Texas Health and Human Services Commission
NEED HELP WITH YOUR APPLICATION?
We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905 (after you pick a language, press 2).
If you have a hearing or speech disability, call 7-1-1 or any relay service.
This form needs
to be filled out,
signed, and sent
back with your
application for
benefits.
Are you afraid
that giving us facts
about someone
could cause harm
(physical or
emotional) to you
or your child?
If yes, you might
not have to give
us facts about that
person. You might
be able to get the
“Family Violence
Exemption.”
• Yourself.
• Your spouse.
• Your children age 20 and younger
who live with you.
• Anyone you include on your tax
return, even if they don’t live with you.
• Anyone else age 20 and younger who
you take care of and lives with you.
(You can still apply for health insurance even if you don’t file a federal income tax return.)
First name
Middle name
Last name
Person 1: (main contact or head of household)
If married, name of spouse:
No
Yes
Do you plan to file a federal income tax return next year? .............................
No
Yes
No
Yes
No
Yes
a. Will you file jointly with a spouse? ...................................................
b. Will you claim any dependents on your tax return? .........................
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone's tax return?.......
If yes, list the name of tax filer: How are you related to the tax filer?
More on page 2-A
Your Tax
Return
If yes, answer questions a to c. If no, skip to question c.
Addendum A . H1010-M
11/2019
Page 2-A
First name
Middle name
Last name
Person 2:
If married, name of spouse:
No
Yes
Do you plan to file a federal income tax return next year? .............................
No
Yes
No
Yes
No
Yes
a. Will you file jointly with a spouse? ...................................................
b. Will you claim any dependents on your tax return? .........................
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone's tax return?.......
If yes, list the name of tax filer: How are you related to the tax filer?
Your Tax
Return
Section 1
(continued)
No
Yes
Does Person 2 live at the same address as Person 1?...................................
If no, what is Person 2's address?
First name
Middle name
Last name
Person 3:
If married, name of spouse:
No
Yes
Do you plan to file a federal income tax return next year? .............................
No
Yes
No
Yes
No
Yes
a. Will you file jointly with a spouse? ...................................................
b. Will you claim any dependents on your tax return? .........................
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone's tax return?.......
If yes, list the name of tax filer: How are you related to the tax filer?
No
Yes
Does Person 3 live at the same address as Person 1?...................................
If no, what is Person 3's address?
If yes, answer questions a to c. If no, skip to question c.
If yes, answer questions a to c. If no, skip to question c.
Addendum A . H1010-M
11/2019
Page 3-A
First name
Middle name
Last name
Person 4:
If married, name of spouse:
No
Yes
Do you plan to file a federal income tax return next year? .............................
No
Yes
No
Yes
No
Yes
a. Will you file jointly with a spouse? ...................................................
b. Will you claim any dependents on your tax return? .........................
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone's tax return?.......
If yes, list the name of tax filer: How are you related to the tax filer?
Your Tax
Return
Section 1
(continued)
No
Yes
Does Person 4 live at the same address as Person 1?...................................
If no, what is Person 4's address?
First name
Middle name
Last name
Person 5:
If married, name of spouse:
No
Yes
Do you plan to file a federal income tax return next year? .............................
If yes, answer questions a to c. If no, skip to question c.
No
Yes
No
Yes
No
Yes
a. Will you file jointly with a spouse? ...................................................
b. Will you claim any dependents on your tax return? .........................
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone's tax return?.......
If yes, list the name of tax filer: How are you related to the tax filer?
No
Yes
Does Person 5 live at the same address as Person 1?...................................
If no, what is Person 5's address?
If more than
5 people are
applying for
benefits, add
more pages with
the same facts.
If yes, answer questions a to c. If no, skip to question c.
Addendum A . H1010-M
11/2019
Page 4-A
Tax deductions
you claim
Section 2
Tell us about
things that can
be deducted on a
federal income tax
return. If anyone
has deductions,
health coverage
costs might
be a little lower.
Information about people applying for benefits
No
Yes
1. Does a child applying for health care travel with a family member
who is a migrant farm worker? ..................................................................
If yes, what is the name of that child or children?
Tax deductions
Mark all that apply, give the amount, and how often you pay it.
(You shouldn’t include a cost that you already considered as part of your net self-employment.)
Alimony paid $
How often?
Student loan interest $
How often?
Other deductions, such as educator expenses, health savings accounts, moving
expenses, tuition and fees $
How often?
Types
If you have any of these deductions, you will need to send us a copy of your last year’s
income tax return.
Section 3
No
Yes
2. Is a child in the Children with Special Health Care Needs program? ........
If yes, who?
No
Yes
3. Is anyone an American Indian or Native Alaskan? .....................................
If yes, you must fill out “Appendix B: American Indian
or Alaska Native Family Member.” It is attached to this form.
4. Was anyone in foster care when they were age 18 or older? ....................
If yes, who?
No
Yes
In which state?
5. Does any child on this application have a parent living
outside of the home? ...................................................................................
No
Yes
Information
about people
applying for
benefits
Addendum A . H1010-M
11/2019
Page 5-A
Money you get
Section 4
Insurance offered through your job
1. Can anyone listed on this form get health insurance through a job? (Check yes even if the
coverage is from someone else's job, such as a parent or spouse.)..........
Money you get
Fill out this section only if the amount of money you get changes or might change from
month to month. If you don’t expect changes to your monthly income, skip this question.
Insurance
offered
through
your job
Section 5
No
Yes
2. Did anyone have insurance through a job and lose it
within the past 3 months?...........................................................................
If yes, who?
No
Yes
If yes, end date:
Your total income this year:
Your total income next year (if you think it will be different):
$
$
If yes, you must fill out “Appendix A: Health coverage from job."
If yes, reason the insurance ended:
Parent’s job ended due to
layoff or business closing.
Parent’s COBRA or ERS
coverage ended.
Change in parent’s
marital status.
CHIP benefits from another
state ended.
Medicaid benefits from
another state ended.
Private health coverage
ended.
Death of a parent.
The child has special
health-care needs.
Medicaid benefits ended
(for any reason).
Others
Read and
sign this
form
Section 6
B. Renewing your health coverage in future years
To make it easier to find out if I can get help paying for health coverage in future years,
I agree to allow the agency to use facts about money I get (income data), including
information from tax returns. The agency will send me a notice, let me make any changes,
and I can cancel (opt out) at any time.
If yes, who is in jail?
No
Yes
I agree: Yes, the agency can get facts listed above and renew my health coverage without asking
me for the next:
5 years (the maximum
number of years allowed)
A. Is anyone who is applying for health coverage
in jail (incarcerated)? .................................................................................
4 years
3 years
2 years
1 years
Don’t use information from
tax returns to renew
my coverage.
/ /
Date (mm/dd/yyyy)
Sign here
APPENDIX A
Appendix A . H1010-M
11/2019
Page 6-A
Health Coverage from Jobs
You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job.
Attach a copy of this page for each job that offers coverage.
Tell us about the job that offers coverage.
Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions.
You only need to include this page when you send in your application, not the Employer Coverage Tool.
EMPLOYEE Information
EMPLOYER Information
Tell us about the health plan offered by this employer.
1. Employee name (First, Middle, Last) 2. Employee Social Security number
3. Employer name
4. Employer Identification Number (EIN)
5. Employer address
6. Employer phone number
7. City
8. State
9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)
12. Email address
( ) -
( ) -
13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If you’re in a waiting or probationary period, when can you enroll in coverage?
List the names of anyone else who is eligible for coverage from this job.
No (Stop here and go to page 9, Section L)
Name:
Name:
Name:
(mm/dd/yyyy)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes
No
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount
for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan?
$
b. How often?
Weekly Every 2 weeks
Twice a month
Once a month Quarterly
Yearly
16. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the
employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan?
$
b. How often?
Weekly Every 2 weeks
Twice a month
Once a month Quarterly
Yearly
Date of change (mm/dd/yyyy):
* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
EMPLOYER COVERAGE TOOL
Appendix A . H1010-M
11/2019
Page 7-A
EMPLOYEE Information
The employee needs to fill out this section.
Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even if it’s
from another person’s job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A.
For example, the answer to question 14 on this page should match question 14 on Appendix A.
Tell us about the health plan offered by this employer.
1. Employee name (First, Middle, Last) 2. Social Security number
3. Employer name
4. Employer Identification Number (EIN)
5. Employer address
6. Employer phone number
7. City
8. State
9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)
12. Email address
( ) -
( ) -
13. Is the employee currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting
or probationary period, when is the employee eligible for coverage?
No (Stop and return this form to employee)
(mm/dd/yyyy)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15)
No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount
for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan?
$
b. How often?
Weekly Every 2 weeks
Twice a month
Once a month Quarterly
Yearly
16. What change will the employer make for the new plan year?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the
employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan?
$
b. How often?
Weekly Every 2 weeks
Twice a month
Once a month Quarterly
Yearly
Date of change (mm/dd/yyyy):
* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for
each employer that offers health coverage.
EMPLOYER Information
Ask the employer for this information.
(Continue)
Does the employer offer a health plan that covers an employee’s spouse or dependent?
(Go to question 14)
Yes Which people?
No
Spouse
Dependent(s)
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.
Appendix B
Appendix B . H1010-M
11/2019
Page 8-A
American Indian or Alaska Native Family Member (AI/AN)
Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your application.
Tell us about your American Indian or Alaska Native family member(s).
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian
health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the
following questions to make sure your family gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach.
1. Name
(First name, Middle name, Last name)
2. Member of a federally recognized tribe?
3. Has this person ever gotten a service from
the Indian Health Service, a tribal health
program, or urban Indian health program,
or through a referral from one of these
programs?
4. Certain money received may not be counted
for Medicaid or the Children’s Health
Insurance Program (CHIP). List any income
(amount and how often) reported on your
application that includes money from
these sources:
• Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties
• Payments from natural resources,
farming, ranching, fishing, leases,
or royalties from land designated as
Indian trust land by the Department
of Interior (including reservations and
former reservations)
• Money from selling things that have
cultural significance
First
First
Middle
Middle
Last
Last
Yes
If yes, tribe name
Yes
If yes, tribe name
No
No
No
Yes
If no, is this person eligible to get
services from the Indian Health Service,
tribal health programs, or urban Indian
health programs, or through a referral
from one of these programs?
Yes
No
No
Yes
If no, is this person eligible to get
services from the Indian Health Service,
tribal health programs, or urban Indian
health programs, or through a referral
from one of these programs?
Yes
No
$
How often?
$
How often?
AI/AN PERSON 1
AI/AN PERSON 2
APPENDIX C
Appendix C . H1010-M
11/2019
Page 9-A
Assistance with Completing this Application
You can choose an authorized representative.
For certified application counselors, navigators, agents, and brokers only.
1. Name of authorized representative (First name, Middle name, Last name)
2. Address
3. Apartment or suite number
7. Phone number
4. City
5. State
6. ZIP code
( ) -
If you want, you can give someone the right to act for you (an authorized representative).
That person can:
• Give and get facts for this application.
• Take any action needed for the application process. This includes appealing an HHSC decision.
• Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
• Take any action needed for you to get benefits. This includes reporting changes and renewing benefits.
If you give someone the right to act for you, that person agrees to:
• fulfill all your responsibilities related to Medicaid;
• keep information about you private;
• obey state and federal laws about conflict of interest and keeping information private, including:
• laws that protect information on people who apply for or receive Medicaid
(42 CFR part 431, subpart F);
• laws about the privacy and safety of personally identifiable information (45 CFR §155.260(f));
• laws barring the state from paying anyone other than your provider or you for Medicaid services,
except in a few circumstances (42 CFR §447.10).
You can have only one authorized representative for all your benefits from HHSC. If you want to change your
authorized representative: (1) log in to your account on YourTexasBenefits.com and report a change, or (2) call 2-1-1
(after you pick a language, press 2). If you’re a legally appointed representative for someone on this application, send
proof with the application.
8. Organization name
9. Organization ID number (if applicable)
By signing, you allow this person to sign your application, get official information about this application,
and act for you on all future matters with this agency.
10. Your signature
11. Date (mm/dd/yyyy)
Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application
for somebody else.
1. Application start date (mm/dd/yyyy)
2. First name, middle name, last name, & suffix
3. Organization name
4. Organization ID number (if applicable)
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