Case Number: 1039987545

07/18/2024

Need Help? Call 2-1-1

or for out of the state callers,
call 1-877-541-7905
Mohammad Bismil Fax: 1-877-447-2839
APT 4305 Apt 4305
337 Kennedale Sublett RD Mail: Texas Health and Human Services
Kennedale TX 76060-2446 Commission
PO Box 149024
Austin Texas 78714-9024
If you have a hearing or speech disability,
call 7-1-1 or any relay service.

To find out if you can get or keep getting benefits, we need more facts from you:
You are getting this packet because either: (1) you applied for benefits, (2) you reported a change to your case, or (3)
we must check your income to see if you can still get benefits.
Inside this packet you will find:
• A list of the items we need from you.
• A pre-paid envelope.

You also might find other forms you can fill out and send to us.

Send us the items by 07/29/2024

If you need help, call us at 2-1-1 or 877-541-7905. After you pick a language, press 2. We can take your call
Monday to Friday, 8 a.m. to 6 p.m. Central Time.
For help or questions about your Lone Star Card account, call 1-800-777-7328 (7EBT).
You still need to send us the items by this due date.

If you don't send us your items by this date,

you might not get benefits or your benefits might end.

There are 4 ways to send us the items we need:

Pick one of these ways to send the items back to us:
• YourTexasBenefits.com: You can upload your items online.

• Your Texas Benefits Mobile App: You can upload your items using the mobile app.
The app is free to download in the Google Play and Apple iTunes stores.

• Mail: Mail this letter and the items we need in the pre-paid envelope that came in this packet.

•
Fax: Fax this letter and the items we need to 1-877-447-2839.

Don't forget:
• Put your case number on everything you send us.
• If you send us a letter or statement showing proof of facts we need, make sure the person who writes it includes:
(1) their name, (2) their address, (3) their phone number, (4) the date they wrote it, and (5) their signature.

Form 1020 Page 1 of 4

12/2022 T-01020-0809037309
 Benefit programs affected and due date:

Program EDG number Due date

For Food Stamp benefits: 693856228 7/29/24

For Medical Assistance: 693856223 8/15/24

For Medical Assistance: 693856222 8/15/24

For Medical Assistance: 701815050 8/15/24

For Medical Assistance: 693856225 8/15/24

For Medical Assistance: 693856224 8/15/24

For Medical Assistance: 717596431 8/15/24

If you're afraid that giving us facts about someone could cause harm (physical or emotional) to you or
your child:
If you're applying for or renewing Medicaid or CHIP benefits, you might not need to give us facts about that
person. You might be able to get the "Family Violence Exemption."
Let us know if you're afraid to give facts about someone:

• Phone: Call 2-1-1 or 1-877-541-7905 (after picking a language, press 2).

• Mail: TEXAS HEALTH AND HUMAN SERVICES COMMISSION,P O Box 149024,

Austin, Texas 78714-9024
• In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 or
1-877-541-7905 (after picking a language, press 1).
• Fax: 1-877-447-2839.

Form 1020 Page 2 of 4

12/2022 T-01020-0809037309
 LIST OF INFORMATION NEEDED AND/OR ACTION REQUIRED:
Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof
Bibi Ghuncha Bismil Medicaid Before we can find out if you can get Medicaid, You don't need to take any action.
Mohammad Bismil we must find out if your child can get Medicaid.
Mohammad Bismil Food Stamps Provide verification of self-employment income Business records and receipts
Medicaid for the following pay periods. 07/15/2024 Checks.
Form 1049 Client's Statement of Self-Employment
Income
Last year's tax return.
Statement from Payment provider or IRS Form 1099
Mohammad Bismil Food Stamps Provide verification of the following missing pay Award letters.
period amounts from 02/01/2021 Payment provider.
Recent checks, stubs, or earnings statements.
Mohammad Bismil Food Stamps Provide verification of your rent. Checks (Cancelled)
Landlord or Property Manager Statement
Lease contract
Receipt

Form 1020-A Page 3 of 4

12/2022 T-01020-0809037309
 Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024

Case Number:1039987545

The enclosed Missing Information form (Form 1020) includes a list of documents you need to send to us
so we can determine your eligibility for services.

See page 1 to find out how to send us your forms.

El formulario adjunto de información faltante (Formulario 1020) incluye una lista de documentos que
usted necesita enviarnos para que podamos determiner si usted reúne los requisitos para los servicios.

Vea la página 1 para saber cómo enviarnos sus documentos.

Form 1020B Page 4 of 4

12/2022 T-01020-0809037309
 TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

Date: 07/18/2024 Need help? Call 2-1-1 or

Case number: 1039987545 1-877-541-7905
Fax: 1-877-447-2839
Mail: TEXAS HEALTH AND HUMAN SERVICES
COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

If you are deaf, hard of hearing, or speech

impaired, call 7-1-1 or 1-800-735-2989.
All numbers are free to call.
MOHAMMAD BISMIL
APT 4305 APT 4305
337 KENNEDALE SUBLETT RD
KENNEDALE TX 76060-2446

Note to Mohammad Bismil :

This form is for your employer. They need to fill out the form and return it by 07/29/2024 . You must agree to let them give facts about you.
Fill out and sign this agreement:

I, (print your name) Mohammad Bismil allow HHSC to give my Social Security number (SSN) to the employer listed on this form.
My SSN can be used to get facts about my employment. I also allow the employer listed on this form to give facts asked on this form to HHSC.

Sign here Date

Employer -- your help is needed:

We need proof that the following person is or was your employee.

Employee or former employee Social Security number

Mohammad Bismil

Some employers might get tax refunds or tax credits for hiring people who get certain state benefits.
To learn more, go to TexasWorkforce.org/wotc or email the Texas Workforce Commission at [email protected].

Employer -- please follow these steps:

This person lives in a home in which someone is applying for state benefits. We need to know the amount of money this person makes or made
from this job.

1. Please fill out the “Proof of Employment” form on the next page.
2. If a question doesn't apply, mark it with "N/A."
3. Return the form by 07/29/2024
To send this back to us, you can either: (a) give it to the employee listed above,
(b) mail it in the pre-paid envelope, or (c) fax it to 1-877-447-2839.

H1028
T-01028-0809037309 03/2021
Page 1
 Texas Health and Human Services Commission
Proof of Employment
To be filled out by the employer Case number : 1039987545
1. Company or employer name:
2. Company or employer address - street, city, state, ZIP:
3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP:
5. Is or was this person your employee? Yes No
If no: Stop here - sign and date the bottom of this form and return it.
If yes: Answer all the questions below. If a question doesn't apply, write "N/A."
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply): Full Time Part time Permanent Temporary
10. Average hours per pay period:
11. Rate of pay: $ per: Hour Day Week Month Job

12. How often paid:

Daily Once a week Every 2 weeks

Twice a month Once a month Other:

13. Does or did this person get overtime pay? Yes - often Yes - rarely No - never
14. FICA or FIT withheld? Yes No
15. Is or was this person on leave without pay? Yes No

If yes: Start date of leave: End date of leave:

16. Does this person have a profit sharing or pension plan? Yes No
If yes: What is the current value? $
17. Does your company offer health insurance? Yes No

If yes: This person is: Not enrolled Enrolled with family members Enrolled for self only
If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months? Yes No

If yes: Explain what will change:

19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts):

Date pay Date Actual Gross pay amount Other pay(include tips, EITC Advance Total Pretax
period ended received hours (before taxes taken out) commissions and bonuses) amount Contributions

20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:

21. Does this person still work for you? Yes No

If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $

Employer - read, sign, and date:

I confirm that this information is true and correct to the best of my knowledge:

Employer -sign here Date Title Phone number H1028

03/2021
T-01028-0809037309 Page 2
Texas Health and Human
Services Commission

STATEMENT OF RESIDENCE MAINTENANCE NEEDS

DECLARACION DE NECESIDADES PARA MANTENAR UNA RESIDENCIA

Name of Applicant /Nombre del Solicitante Application No. /Solicitud No.

Mohammad Bismil T045873574
Applicant Home Address /Dirección de Residencia del Solicitante
APT 4305 Apt 4305 337 Kennedale Sublett RD Kennedale TX 76060-2446

TO BE COMPLETED BY APPLICANT /EL SOLICITANTE DEBE LLENAR ESTA SECCION

This is my statement that I was living at the above Declaro que antes de entrar a la casa para
residence prior to admission to the nursing facility and I convalecientes, yo estaba viviendo en la dirección anotada
intend to return to the above residence within six antes, y que tengo intenciones de volver a vivir allí dentro
months of my admission to the nursing facility. I need de los seis meses contados desde mi entrada a la casa
to pay the following expenses to maintain the residence para convalecientes. Para mantener la residencia
until my return: mencionada antes hasta mi regreso, necesito pagar los
siguientes gastos:
Monthly Mortgage or Rent
Hipoteca o Renta Mensual $

Average Monthly Utilities (excluding telephone)

Promedio de Cuentas de Servicios (sin tener en cuenta el teléfono) $

X
Signature - Applicant /Firma - Solicitante Date /Fecha

TO BE COMPLETED BY ATTENDING PRACTITIONER — As the above-named patient’s attending practitioner, I certify

that the patient is likely to return to his/her residence within six months of admission to the nursing facility.
Name of Practitioner (please type or print)

Signature - Practitioner Date

Address of Practitioner Telephone No.

Form H1280
August 2012 T-01280-0809037309
This page intentionally left blank
Texas Health and Human
Services Commission Facts about Self-Employment Income

Self-employment income is any money you make working for yourself or as a subcontractor.
If you have an employer who pays you and takes out taxes, you're not self-employed.
You might be self-employed if you are a: babysitter, landscaper, day laborer, house cleaner, hair stylist, auto mechanic, or
person who makes money from sales, crops, leases, commissions, fees, or anything you do or sell.

If anyone on your benefits case gets money from self-employment, you need to: (1) fill out this form and return it to us and (2)
send proof of the facts you give on this form: receipts, invoices, or other papers (all original items sent with this form will be
returned to you).

You also can send proof of the facts you give on this form by uploading your papers and forms
on the Your Texas Benefits Mobile App, or our website, YourTexasBenefits.com.

If you use this form to show your self-employment income:

• Answer all questions and sign and date at the bottom. This is your sworn statement of income.
• You can ask another person to help you fill out this form, but that person also must sign this form.
• Use more sheets of paper if you need to. You must sign and date each sheet.

1. Name (person getting money from self-employment): Mohammad Bismil

2. What type of work do you do to earn this money?

3. How many hours do you work each week?

4. Fill out the table below to tell us how much money you get from self-employment.

How to fill out the table:

• Tell us about money from self-employment from the past 2 months. If you don't get paid every month, tell us about your
most recent payments.
• List the date you were paid, who paid the money, and the amount paid.
• Add the income amounts and enter the total in the box "Total self-employment income."

Date Who paid this money Amount paid

Total self-employment income: $

Form 1049
Page 1 / 12-2015
T-01049-0809037309
5. Fill out the table below to tell us how much it costs for you to work (self-employment expenses).
Expenses can include:
• Equipment. • Materials used to make a product. • Operating supplies.
• Business rent and utilities. • Interest paid on business loans. • Business property.
• Repairs to business equipment or vehicles. • Costs of labor (list each person and the amount
• Advertising (signs, flyers). you paid them).
• Professional fees, legal fees, licenses and permits.
Expenses can't include:
• Rent, taxes, utilities, or interest on mortgage for your business if it operates out of your home (unless these costs are
separate from the costs of your home).
• The cost of goods you buy for the business, but use yourself.
How to fill out the table:
• Tell us about expenses from the past 2 months.
• If you don't pay an expense every month, tell us about your most recent expenses.
• List the date of the expense, the type of expense, and the amount of the expense.
• Add the expenses and enter the total in the box "Total self-employment expenses."

Date Type of expense Amount paid

Total self-employment expenses: $

Reminder ► Send proof of the facts you gave on this form: receipts, invoices, or other papers.
Who must sign ► The form must be signed by the person getting self-employment income or their spouse or authorized
representative. Anyone can help you fill out the form, but that person also must sign this form.
By signing below, I agree that: The answers on this form are true and complete to the best of my knowledge.
If they aren't, I know I might: (1) be charged with a crime, and (2) have to repay benefits.

Signature of person getting self-employment income Date Signature of anyone helping you fill out this form Date
In most cases, you can see and get facts HHSC has about you. This includes facts you give HHSC and facts HHSC gets from
other sources (medical records, employment records, etc.). You might have to pay to get a copy of these facts. You can ask
HHSC to fix anything that is wrong. You do not have to pay to fix a mistake. To ask for a copy or fix a mistake, call 2-1-1 or
1-877-541-7905 (after you pick a language, press 2).
FOR AGENCY USE ONLY
Case name Case number
Mohammad Bismil 1039987545
Form 1049
Page 2 / 12-2015
T-01049-0809037309