Please use dark ink. Please print. If you need more room, add pages.

Your Texas Benefits: Form Fill in the circles ( ) like this

Section A Mark the benefits anyone on your case is applying for: Health-care benefits:
Children Adult caring for a Child
SNAP Food Benefits TANF Cash Help
Your Facts ●
for Families
● Adult not caring for a Child
Pregnant Woman
TSAP Food Benefits
If you’re applying to
get SNAP food
benefits, the first Person 1: contact person or head of household
month’s amount will
be based on the date we Miranda Kasper
get pages 1 and 2. First name Middle name Last name

Other benefits also are 2 2 0 - 4 1 - 6 8 0 0 0 8 / 1 8 / 1 9 9 4

based on when we get
pages 1 and 2. Social Security number Birth date (month/day/year)
PO Box 3073
If you send only Mailing address
pages 1 and 2 now,
you will still need to Texas City Texas 77592
fill out the rest of the State ZIP
City
application to get
benefits. (912) 689-9635 (912) 689-9635
Home phone Cell or daytime phone
You have the right
to file this form 3701 Manor Ln Galveston
immediately if it has
your name, address, Home address County
and signature. Dickinson Texas 77539
City State ZIP

Section B You might be able to get SNAP food benefits the next work day if you:
• Are a migrant or seasonal farm worker,
SNAP Food • Have $100 or less in available cash and bank accounts and expect to earn less than
$150 this month, or
Benefits • Have costs for housing or utilities that are more than your cash, bank accounts and
This section is the income you expect for the month.
only for people Answer them for everyone living in your home.
applying for 1. Is anyone in the home a migrant worker or a seasonal farm worker? .................. Yes ● No
SNAP food
benefits. 2. Does anyone in the home have money in the bank or
cash? .................................................................................. Yes ● No
Amount
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) .................. Yes ● No Amount
Find out how to
return your form: 4. Does anyone in the home pay costs for housing and
See page 3. utilities? (This includes rent, mortgage, water, gas,
electric, sewage, trash, phone and property tax.) ............. Yes ● No Amount

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 (or have someone with the right to act for you sign) Date
More on page 2

H1010
Application for benefits 12/2023
Texas Health and Human Services Commission Page 1
Section C Is anyone in your home pregnant? ........................................................................... Yes ● No

Pregnant
Women Number of
babies expected
If yes, who?
This section is only
for people applying Is this your first pregnancy? .......... Yes No Due date / /
for health-care
benefits. What is the first and last name of the unborn child’s father?

First name Last name

Was anyone in your home pregnant during the last 12 months? .......................... Yes No

/ /
If yes, who?
When did the pregnancy end?

Section D Is anyone an active duty member of one of these military forces?

• U.S. Armed Forces
Military • National Guard
Service • Reserves
• State Military Forces .......................................................................... Yes ● No
This section is only
for people applying
for health-care
benefits.
If yes, who?

Social security number: H1010

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Section E 1. Most people applying for benefits must be interviewed.
We often interview people on the phone.
Interview It helps to know if any of the reasons below make it hard for you to get to a benefits office:
Help • You live more than 30 • Your work or training • You are a victim of
miles from the closest hours don’t allow you to family violence.
benefits office. get to a benefits office
when it’s open. • You take care of
• You can’t get a ride. someone in your home.
• You can’t travel because
• The weather is bad. you are age 60 or older,
• You are sick. or you have a disability.

Do any of the reasons above apply to you? ...................................................... ● Yes No

2. If you come to our office, will you need special help or equipment? ................. Yes ● No

If yes, what do you need?

3. What language do you want to speak during the interview? English

4. Will you need an interpreter? We can get one for you for free. ......................... Yes ● No
If yes, mark the one you need:
Spanish Vietnamese
American Sign Language Other:

Social security number: H1010

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Your Texas Benefits: Form
Fill in the circles ( ) like this
Please use dark ink. Please print. If you need more room, add pages.

Section F
Contacting Person 1: Contact Person or Head of Household
You Miranda Kasper
First name Middle name Last name

2 2 0 - 4 1 - 6 8 0 0 0 8 / 1 8 / 1 9 9 4
Social Security number Birth date (month/day/year)

[email protected]
E-mail
Are you applying for benefits for yourself or a child? ......................................... ● Yes No
If yes, give your facts below:

Section G Person 1
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 Divorced Live in Texas? ● Yes No
Mark the benefits Separated Widowed Plan to stay in Texas? ● Yes No
Person 1 is applying for:
● SNAP Food Benefits Male ● Female Hispanic or Latino? ............................. Yes ● No
TSAP Food Benefits Optional
Questions Mark one or more: American Indian or Alaska Native Asian
TANF Cash Help Black or African-American Native Hawaiian or Pacific Islander ● White
for Families:
TANF Are you going to school? ..... Yes ● No If yes, are you going full-time? ..... Yes No
One-Time TANF
Are you a U.S. citizen? If no, give facts below. .................................................. ● Yes No
One-Time TANF for Relatives

Health-care benefits for: Are you a refugee or legally admitted immigrant? .................................................... Yes No
Children / /
Adult Caring for a Child Date you entered the U.S. (month/day/year)
If you have a sponsor, write your sponsor’s name
● Adult not caring for a Child
Pregnant Woman Are you registered with the U.S.
Citizenship and Immigration Services? Yes No Immigrant registration number
Women 15-44 years old who do not qualify for Medicaid or CHIP are automatically tested for Healthy Texas Women (HTW)
eligibility. Check the box below if you waive HTW testing.
I do not want to be tested for HTW
Return this completed form Use pages 4 and 5 for other
by fax, mail, or in person: people applying for benefits.
Fax: 1-877-447-2839 If you need more pages, you can:
• Add a blank page and write in your facts.
Mail: HHSC, PO Box 149024 OR
Austin, TX 78714-9968 • Go to www.hhsc.state.tx.us to get an
In person: Call 2-1-1 to find an HHSC extra page.
benefits office near you. Click on “How to Get Help.”

H1010
Application for benefits 12/2023
Texas Health and Human Services Commission Page 4
Section H Person 2: adult or child applying, spouse of person applying, or parent living with a child who is applying

People
First name Middle name Last name
Applying
for Benefits - - / /
Social Security number Birth date (month/day/year)
If this person gets money from
Social Security or railroad
This person's relationship to you
retirement, list the number here: Social Security claim # Railroad retirement #
Mark the benefits Married Single Divorced Live in Texas? Yes No
Person is applying for:
Separated Widowed Plan to stay in Texas? Yes No
SNAP Food Benefits
TSAP Food Benefits Male Female Hispanic or Latino? ................................................ Yes No
Optional
Questions Mark one or more: American Indian or Alaska Native Asian
TANF Cash Help Black or African-American Native Hawaiian or Pacific Islander White
for Families:
TANF
Is this person going to school? Yes No If yes, is this person going full-time? Yes No
One-Time TANF Is this person a U.S. citizen? If no, give facts below. ................................................. Yes No
One-Time TANF for Relatives
Is this person a refugee or legally admitted immigrant? .............................................. Yes No
Health-care benefits for:
Children / /
Adult Caring for a Child If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
Adult not caring for a Child Is this person registered with the U.S.
Pregnant Woman Citizenship and Immigration Services? ... Yes No Immigrant registration number
I do not want to be tested for HTW

Person 3: adult or child applying, spouse of person applying, or parent living with a child who is applying

First name Middle name Last name

- - / /
Social Security number Birth date (month/day/year)
If this person gets money from
Social Security or railroad
This person's relationship to you Social Security claim # Railroad retirement #
retirement, list the number here:
Mark the benefits Married Single Divorced Live in Texas? Yes No
Person is applying for:
Separated Widowed Plan to stay in Texas? Yes No
SNAP Food Benefits
TSAP Food Benefits Male Female Hispanic or Latino? ................................................ Yes No
Optional
Questions Mark one or more: American Indian or Alaska Native Asian
TANF Cash Help Black or African-American Native Hawaiian or Pacific Islander White
for Families:
TANF
Is this person going to school? Yes No If yes, is this person going full-time? Yes No
One-Time TANF Is this person a U.S. citizen? If no, give facts below. ................................................. Yes No
One-Time TANF for Relatives
Is this person a refugee or legally admitted immigrant? .............................................. Yes No
Health-care benefits for:
Children / /
Adult Caring for a Child If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
Adult not caring for a Child Is this person registered with the U.S.
Pregnant Woman Citizenship and Immigration Services? ... Yes No Immigrant registration number
I do not want to be tested for HTW

H1010
Application for benefits 12/2023
Texas Health and Human Services Commission Page 5
Section H Person 4: adult or child applying, spouse of person applying, or parent living with a child who is applying

People
First name Middle name Last name
Applying
for Benefits - - / /
Social Security number Birth date (month/day/year)
If this person gets money from
Social Security or railroad
This person's relationship to you
retirement, list the number here: Social Security claim # Railroad retirement #
Mark the benefits Married Single Divorced Live in Texas? Yes No
Person is applying for:
Separated Widowed Plan to stay in Texas? Yes No
SNAP Food Benefits
TSAP Food Benefits Male Female Hispanic or Latino? ................................................ Yes No
Optional
Questions Mark one or more: American Indian or Alaska Native Asian
TANF Cash Help Black or African-American Native Hawaiian or Pacific Islander White
for Families:
TANF
Is this person going to school? Yes No If yes, is this person going full-time? Yes No
One-Time TANF Is this person a U.S. citizen? If no, give facts below. ................................................. Yes No
One-Time TANF for Relatives
Is this person a refugee or legally admitted immigrant? .............................................. Yes No
Health-care benefits for:
Children / /
Adult Caring for a Child If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
Adult not caring for a Child Is this person registered with the U.S.
Pregnant Woman Citizenship and Immigration Services? ... Yes No Immigrant registration number
I do not want to be tested for HTW

Person 5: adult or child applying, spouse of person applying, or parent living with a child who is applying

First name Middle name Last name

- - / /
Social Security number Birth date (month/day/year)
If this person gets money from
Social Security or railroad
This person's relationship to you Social Security claim # Railroad retirement #
retirement, list the number here:
Mark the benefits Married Single Divorced Live in Texas? Yes No
Person is applying for:
Separated Widowed Plan to stay in Texas? Yes No
SNAP Food Benefits
TSAP Food Benefits Male Female Hispanic or Latino? ................................................ Yes No
Optional
Questions Mark one or more: American Indian or Alaska Native Asian
TANF Cash Help Black or African-American Native Hawaiian or Pacific Islander White
for Families:
TANF
Is this person going to school? Yes No If yes, is this person going full-time? Yes No
One-Time TANF Is this person a U.S. citizen? If no, give facts below. ................................................. Yes No
One-Time TANF for Relatives
Is this person a refugee or legally admitted immigrant? .............................................. Yes No
Health-care benefits for:
Children / /
Adult Caring for a Child If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
Adult not caring for a Child Is this person registered with the U.S.
Pregnant Woman Citizenship and Immigration Services? ... Yes No Immigrant registration number
I do not want to be tested for HTW

H1010
Application for benefits 12/2023
Texas Health and Human Services Commission Page 6
 Section I 1st child's name:
More Facts
About Children /
Father's birth date
/
Father's first and last name
Age 18 or
Younger - -
FATHER
Father's Social Security number Father's phone

This section is Father's mailing address City State ZIP

only for children Father is: In home Out of home Deceased Employer
applying for TANF
cash help for
families.
Mother's first and last name Mother's maiden name

- - / /
Mother's Social Security number Mother's birth date
MOTHER

Time Saving Tip

You only need to give
facts for each father Mother's mailing address City State ZIP
and mother one time.
Mother's phone Employer
If a child has the same
mother or father as Mother is: In home Out of home Deceased
another child, you can
write something like Were these parents ever married to each other? .................................................... Yes No
“same as 1st child”
where the parent’s
name would go. 2nd child's name:

/ /
Father's first and last name Father's birth date
Are you afraid that - -
giving facts about the
FATHER

child’s other parent Father's Social Security number Father's phone

might put you or your
children in danger?
You might not have to Father's mailing address City State ZIP
help or cooperate with Father is: In home Out of home Deceased Employer
the Office of Attorney
General to collect child
or medical support if you
are afraid. You can ask
not to give these facts by: Mother's first and last name Mother's maiden name

• Telling your benefits

- - / /
Mother's Social Security number Mother's birth date
MOTHER

advisor (or designated

representative) reasons
why this might put
you or your children
in danger. Mother's mailing address City State ZIP
Mother's phone Employer
• Signing the Good
Cause request form. Mother is: In home Out of home Deceased
(Your benefits advisor
has this form.) Yes No
Were these parents ever married to each other? ....................................................

H1010
Application for benefits 12/2023
Texas Health and Human Services Commission Page 7
Section I 3rd child's name:
More Facts
About Children / /
Father's first and last name Father's birth date
Age 18 or
Younger - -
FATHER
(continued) Father's Social Security number Father's phone

Father's mailing address City State ZIP

Are you afraid Father is: In home Out of home Deceased Employer
that giving us facts
about someone
could cause harm
(physical or Mother's first and last name Mother's maiden name
emotional) to you
or your child? - - / /
If yes, you might Mother's Social Security number Mother's birth date
MOTHER

not have to give us

facts about that
person. You might
be able to get the Mother's mailing address City State ZIP
"Family Violence
Exemption." Mother's phone Employer
Mother is: In home Out of home Deceased

Were these parents ever married to each other? .................................................... Yes No

4th child's name:

/ /
Father's first and last name Father's birth date

- -
FATHER

Father's Social Security number Father's phone

Father's mailing address City State ZIP

Father is: In home Out of home Deceased Employer

Mother's first and last name Mother's maiden name

- - / /
Mother's Social Security number Mother's birth date
MOTHER

Mother's mailing address City State ZIP

Mother's phone Employer
Mother is: In home Out of home Deceased

Were these parents ever married to each other? .................................................... Yes No

H1010
Application for benefits 12/2023
Texas Health and Human Services Commission Page 8
Section J Other people in the home
Other People These people live in my home, but they don’t want to apply for benefits.
in the Home (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.

Name Relationship to you Birth date (if relative)

Name Relationship to you Birth date (if relative)

Name Relationship to you Birth date (if relative)

Section K Information about people applying for benefits

Help Us Serve 1. Does a child applying for health care travel with a family
member who is a migrant farm worker? ................................................................ Yes No
You Better ●

2. Is a child in the Children with Special Health Care Needs program? ............... Yes ● No
This section is
only for people
applying for
health-care benefits.
If yes, who?

3. Is anyone an American Indian or Native Alaskan? ............................................... Yes No

These questions will

not be used to decide
if your family can If yes, who? What tribe?
get benefits.

Section L Other Facts

Other Facts 1. Does anyone have a disability? ................................................................................ Yes ● No

If yes, who?

2. Is anyone getting TANF cash help for families, SNAP food

benefits or health-care benefits from another state? ............................................... Yes ● No

If yes, who? Which state? When did that person last get benefits?

Social security number: H1010

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Section L 3. Has anyone been convicted of a felony that:
(1) took place after August 22, 1996, and (2) involved illegal drugs? .................. Yes ● No
Other Facts
(continued)
If yes, who?

4. Is anyone living in a place of care such as:

•A homeless shelter •A drug treatment center
Answer 3, 4 and 5 •A family violence shelter
only if anyone •A group home .............................................. Yes No
is applying for
TANF cash help for
families or SNAP
food benefits. If yes, who?

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 for families
or SNAP food benefits.

Is anyone living with you disqualified from getting TANF cash help
for families or SNAP food benefits anywhere in the United States? .................... Yes ● No

Section M Other health insurance

Medical Facts Does anyone have health insurance other than Medicare, Medicaid, or CHIP? ..... Yes ● No
If yes, give facts below.
This section is
only for people
applying for TANF
cash help for Name of insured person (first, middle, last) Insurance company
families or
health-care benefits.
Policy number Coverage start date Coverage end date

Type of coverage How much is your premium? Who pays the premium?

Reason coverage ended Amount you pay each month to cover

your children on this insurance

Name of insured person (first, middle, last) Insurance company

Policy number Coverage start date Coverage end date

Type of coverage How much is your premium? Who pays the premium?

Amount you pay each month to cover

Reason coverage ended
your children on this insurance.

Social security number: H1010

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Section M Medical bills from the past 3 months
Medical Facts If anyone on your case can't pay their medical bills, Medicaid might pay them.
(continued)
•The bills must be for services they got in the past 3 months.
This section is •You need to show proof of money you get (income) for the month(s) they got services.
only for people
applying for TANF Does anyone applying for benefits have medical bills for services they
cash help for got in the past 3 months? ............................................................................................. Yes ● No
families or
health-care benefits.

if yes, who? (first, middle, last)

Section N Vehicles
Things Does anyone own or is anyone paying for a:
Anyone is •car •truck •boat •motorcycle •other .......................................... Yes No
If yes, give facts below.
Paying for
or Owns
Name of owner (first, middle, last) Make/Model Year
Skip this section
VEHICLE 1

if you are applying

only for health-care Name of co-owner if also owned by someone outside the home
benefits.
Vehicle is used for a person with a disability.
Money still owed on vehicle

If you need
Name of owner (first, middle, last) Make/Model Year
more room, add
more pages with
VEHICLE 2

the same facts. Name of co-owner if also owned by someone outside the home

Vehicle is used for a person with a disability.

Money still owed on vehicle

Name of owner (first, middle, last) Make/Model Year

VEHICLE 3

Name of co-owner if also owned by someone outside the home

Vehicle is used for a person with a disability.

Money still owed on vehicle

Social security number: H1010

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Section N Things anyone is paying for or owns
Things We need to know about items anyone owns or is paying for, such as:
Anyone is • cash • bank accounts • homes and other property • insurance policies • stocks
Paying for Does anyone own or is anyone paying for these types of items? ............................... Yes ● No
If yes, give facts below.
or Owns
(continued)
Item Account number Value
Skip this section
Item 1

if you are applying

only for health-care Names on account or deeds (include co-owners)
benefits.
Name and address of bank or business (to contact about item)

Item Account number Value

Item 2

Names on account or deeds (include co-owners)

Name and address of bank or business (to contact about item)

Item Account number Value

Item 3

Names on account or deeds (include co-owners)

Name and address of bank or business (to contact about item)

Section O Money anyone might get from other programs

Money Is anyone waiting for an answer on an application for one of
the programs listed below? .................................................................................... Yes No
Coming into ●

the Home If yes, mark the program anyone is waiting to hear from.

Social Security (RSDI) Supplemental Security Income (SSI)

Other disability Unemployment compensation benefits

Name of person waiting for an answer Program Name

Social security number: H1010

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Section O Money from jobs or training
Money Did anyone get money in the past 3 months from:
Coming into (a) working for someone else (b) training, or (c) working for themselves?............... Yes ● No
If yes, give facts below.
the Home
(continued) before taxes and
deductions are taken out
Name of person who got money from a job Hours worked Amount paid
How often are you paid? twice a month
daily
Start date Last payment date (month/year) once a month
once a week
every 2 weeks other:
Job 1

Is this person still working at this job or in training?.................................... Yes No

Was this person working for themselves? ...................................................... Yes No
If no, list the person or place that paid the money.

Your job may take money out of your check before taxes. These are pretax contributions. They
may be for retirement savings, medical insurance premiums, a health savings account, dependent
care expenses, commuter expenses or life insurance premiums.

Total pretax contributions per pay period How often is it contributed Date contributed
before taxes and
deductions are taken out
Name of person who got money from a job Hours worked Amount paid
How often are you paid?
twice a month
daily
Start date Last payment date (month/year) once a week once a month
every 2 weeks other:
Job 2

Is this person still working at this job or in training?.................................... Yes No

Was this person working for themselves? ...................................................... Yes No
If no, list the person or place that paid the money.

Total pretax contributions per pay period How often is it contributed Date contributed

Social security number: H1010

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Section O before taxes and
deductions are taken out
Name of person who got money from a job Hours worked Amount paid
Money How often are you paid?
twice a month
Coming into Start date Last payment date (month/year)
daily
once a month
once a week
the Home every 2 weeks other:
Job 3
(continued)
Is this person still working at this job or in training?.................................... Yes No
Was this person working for themselves? ...................................................... Yes No
If no, list the person or place that paid the money.

Total pretax contributions per pay period How often is it contributed Date contributed

Social security number: H1010

Application for benefits 12/2023
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Section O Other Money
Money Does anyone get, or expect to get, any of the types of money listed below? ............... Yes ● No
Coming into If yes mark other types of money anyone gets or might get soon.
the Home Supplemental Security Cash or gifts. Loans paid to anyone
(continued) Income (SSI). Payments after being hurt at on your case.
Social Security. work (worker's compensation). Payments from private insurance
Retirement benefits. Payments after losing a job Payments to help with utilities
Veterans benefits. (unemployment compensation). Rent paid to you.
Child support anyone gets. Alimony/Spousal Support Other
Interest or dividends.
If anyone gets, or expects to get, any of these types of money, give the facts below.

Type of money (item you marked above) Amount you get paid Last payment date (month/year)
How often are you paid?
MONEY TYPE 1

daily
once a week
Name of person getting this money (if child support, list child's name) every 2 weeks
twice a month
once a month
Person, company, or agency paying the money other:

Type of money (item you marked above) Amount you get paid Last payment date (month/year)
How often are you paid?
MONEY TYPE 2

daily
once a week
Name of person getting this money (if child support, list child's name) every 2 weeks
twice a month
once a month
Person, company, or agency paying the money other:

Type of money (item you marked above) Amount you get paid Last payment date (month/year)
How often are you paid?
MONEY TYPE 3

daily
once a week
Name of person getting this money (if child support, list child's name) every 2 weeks
twice a month
once a month
Person, company, or agency paying the money other:

Social security number: H1010

Application for benefits 12/2023
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Section P Housing costs
Housing Costs 1. Does anyone pay any of the costs listed below for the home they are living in?
Or for a home they plan to return to? ................................................................ Yes ● No
This section is only
for people applying If yes, mark the costs Rent or home payment Natural gas/propane
for SNAP food benefits. they have and list Tax on home Phone
the amount: Water and sewer Home insurance
Electricity Other

2. Does anyone not on your case and not living in your home help
pay your housing costs? .................................................................................. Yes ● No

Section Q Costs to take care of others Examples:

•Child care costs so someone can work,
Costs to Does anyone have costs look for work, go to training, or go to school.
Take Care to take care of others? Yes No •Child support payments, medical bills, and health
insurance you pay for a child living outside the home.
of Others If yes, give facts below. •Alimony payments.
•Costs for people with disabilities or adults
who need help caring for themselves.
How often paid?
daily
Type of cost First name of person who gets care or support once a week
every 2 weeks
twice a month
Who pays the cost? Amount paid Date last paid once a month
COST 1

other:

For court ordered child support

Person or company that gets the money (name, address, and phone number) list child who gets support
(provide copy of court order)
How often paid?
daily
Type of cost First name of person who gets care or support once a week
every 2 weeks
twice a month
Who pays the cost? Amount paid Date last paid once a month
COST 2

other:

For court ordered child support

Person or company that gets the money (name, address, and phone number) list child who gets support
(provide copy of court order)

Social security number: H1010

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Section R Medical costs
Medical Costs Does anyone age 60 or older, or anyone with a disability,
pay medical costs?........................................................................................................ Yes No
This section is
only for people
applying for SNAP If yes, mark the type of costs they pay:
food benefits or Doctor Hospital Medicine Health insurance
health-care
benefits.

Preferred Method of Contact by Health Plan Providers

or Managed Care Organizations
If you get health benefits from us, your health plan provider or managed care organization(MCO)
may contact you for the following:

• Appointment reminders
• Eligibility and Enrollment matters
• Information about your health care matters
• Other important notices

You can choose to receive this contact by phone, text message or email.

Text message and e-mail are not encrypted and may not be secure. The risks include an unauthorized
third party intercepting confidential or private information. If one of these is your preferred method
of communication for your health care, be aware of these risks when sending your personal
information by text or email.

Your MCO or health plan provider must take reasonable steps to make sure that your health care
information stays private.

By completing the information below, you acknowledge that you understand the risks associated
with receiving electronic communications and consent to HHSC sharing your preferred method of
contact with your MCO or health plan provider.

Select your preferred contact method from the list below.

Name : Miranda Kasper

Language you prefer to be contacted in : English

Telephone number: (912) 689-9635

3 By telephone (If contacted by cell phone, the call may be auto-dialed or pre-
recorded, and your carrier’s usage rates may apply.)
1 By text message Cell phone number: (912) 689-9635
(Carrier message and data rates may apply)
2 By e-mail
E-mail address: [email protected]
If you choose to provide this information, you will be responsible for notifying your MCO or
health plan provider of any changes to your contact information. You can opt out of being
contacted by telephone, text message, or email by notifying your MCO or health plan provider.

Social security number: H1010

Application for benefits 12/2023
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Section S People helping you
People Did someone help you fill out this form? .................................................................. Yes ● No
Helping
You If yes, tell us about that person:

Name

Relationship or organization Phone

Address

Section T Signing up to vote

Signing Up Applying to register or declining to register to vote will not affect the
amount of assistance that you will be provided by this agency.
to Vote
(optional) If you are not registered to vote where you live now, would
you like to apply to register to vote here today? ................................................. Yes ● No
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

Already registered Client declined Agency transmitted
Client to mail Mailed to client Other Agency staff signature

Social security number: H1010

Application for benefits 12/2023
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Section U 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).
A Person That person can:
• Give and get facts for this application
Who Can • Take any action needed for the application process. This includes appealing an HHSC decision.
Act for You • Take any action needed to enroll in health-care benefits. This includes picking a health plan.
• Take any action needed 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;
Don't forget • 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
to sign the 431, subpart F);
• laws about the privacy and safety of personally identifiable information (45 CFR
last page. §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).
Do you want to give someone the right to act for you - to be your
authorized representative? ........................................................................................... Yes ● No
If yes, tell us about that person (the authorized representative):

Name of person who you want to have the right to act for you.

Address

Phone

Social security number: H1010

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Section V Legal information
Legal Your Right to be Treated Fairly
This institution is an equal opportunity provider.
This institution is prohibited from discriminating on the basis of race,
Information color, national origin, disability, age, sex and in some cases religion or You also can file a complaint with the Texas Health and Human Services
political beliefs. Commission, Civil Rights Office. Email [email protected].
tx.us, call 1-888-388-6332, fax (512) 438-5885, or write Texas Health
The U.S. Department of Agriculture also prohibits discrimination and Human Services Commission, Civil Rights Office, 701 W. 51st St., MC
based on race, color, national origin, sex, religious creed, disability, W206, Austin, Texas 78751.
age, political beliefs or reprisal or retaliation for prior civil rights
activity in any program or activity conducted or funded by USDA. Citizenship and Immigration Status
Persons with disabilities who require alternative means of
communication for program information (e.g. Braille, large print, You can get benefits for your children who are U.S. citizens or legal
audiotape, American Sign Language, etc.), should contact the Agency immigrants even if you are not a U.S. citizen or a legal immigrant. You
(State or local) where they applied for benefits. Individuals who are do not have to give your citizenship or immigration status to get
deaf, hard of hearing or have speech disabilities may contact USDA benefits for your children. You only have to give the citizenship or
through the Federal Relay Service at (800) 877-8339. Additionally, immigration status of people who want benefits. If you are not a U.S.
program information may be made available in languages other than citizen or a legal immigrant, the only benefits you might be able to get
English. are emergency Medicaid services. Getting long-term care (Medicaid for
the Elderly and People with Disabilities) or cash help (TANF) could affect
Supplemental Nutrition Assistance Program (SNAP) your immigration status and your chances of getting a Permanent
Resident Card (green card). Getting other benefits will not affect your
To file a program complaint of discrimination, complete the USDA immigration status and your chances of getting a Permanent Resident
Program Discrimination Complaint Form, (AD-3027), found online at: Card. You might want to talk to an agency that helps immigrants with
http://www.ascr.usda.gov/complaint_filing_cust.html legal questions before you apply. If you are a refugee or have been given
and at any USDA office, or write a letter addressed to USDA and asylum, getting benefits will not affect your chances of getting a
provide in the letter all of the information requested in the form. To Permanent Resident Card or becoming a citizen.
request a copy of the complaint form, call (866) 632-9992. Submit Social Security Numbers
your completed form or letter to USDA by: #

(1) mail: U.S. Department of Agriculture Office of the Assistant You only need to give the Social Security numbers (SSNs) for people who
Secretary for Civil Rights 1400 Independence Avenue, SW want benefits. Giving or applying for an SSN is voluntary; however,
Washington, D.C. 20250-9410 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
(2) fax: (202) 690-7442; or 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
(3) email: [email protected]. 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
For any other information dealing with Supplemental Nutrition amount of money you get (income), if you can get benefits, and the
Assistance Program (SNAP) issues, persons should either contact the amount of benefits you can get. (7 C.F.R 273.6 for food benefits; 45 C.F.R
USDA SNAP Hotline Number at (800) 221-5689, which is also in 205.52 for TANF; and 42 C.F.R 435.910 for health care.)
Spanish or call the State Information/Hotline Numbers (click the link
for a listing of hotline numbers by State); found online at: Important Information for Former Military Service
http://www.fns.usda.gov/snap/contact_info/hotlines.htm Members
Medicaid and Temporary Assistance for Needy
Families Women and men who served in any branch of the United States Armed
Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves
To file a complaint of discrimination regarding a program receiving or National Guard, may be eligible for additional benefits and services.
Federal financial assistance through the U.S. Department of Health For more information, please visit the Texas Veterans Portal at https://
and Human Services (HHS), write: HHS Director, Office for Civil Rights, veterans.portal.texas.gov.
Room 509F , 200 Independence Avenue, S.W., Washington, D.C.
20201 or call (800) 368-1019 (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 [email protected], 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.

Social security number: H1010

Application for benefits 12/2023
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Section W Statement of Understanding
Read Section W before signing the last page.

All Benefit Programs SNAP Food Benefits

Facts HHSC Has About Me Telling the Truth
Anyone who applies for or gets SNAP must:
HHSC uses facts about people applying for benefits to • Tell the truth.
decide: (1) who can get benefits, and (2) the amount • Never trade or sell SNAP benefits, Lone Star Cards, or other
of benefits. HHSC checks facts with the federal devices that allow people to get SNAP.
Income and Eligibility Verification System. If any
facts don't match, HHSC will check other sources
(banks, employers, etc.). If anyone applying for Anyone who chooses not to tell the truth might:
benefits has an immigration registration number, • Not get SNAP for a year or more.
HHSC must check with the U.S. Citizenship and • Be fined up to $250,000, jailed up to 20 years, or both.
Immigration Services' (USCIS) system. HHSC • Lose income tax refunds.
will not give anyone's facts to USCIS. • Be charged with other crimes.
• Have to repay benefits.
In most cases, I can see and get facts HHSC has about
• Never get SNAP again.
me. This includes facts I give HHSC and facts HHSC
gets from other sources (medical records, employment If a court of law finds you guilty of using or receiving benefits in a
records, etc.). I might have to pay to get a copy of transaction involving the sale of a controlled substance, you will be not
these facts. I can ask HHSC to fix anything that is be eligible for benefits for two years for the first offense, and
wrong. I do not have to pay to fix a mistake. To ask permanently for the second offense.
for a copy or to fix a mistake, I can call 2-1-1 or my
local HHSC benefits office. If a court of law finds you guilty of having used or received benefits in a
transaction involving the sale of firearms, ammunition or explosives,
Keeping My Facts Private you will be permanently ineligible to participate in the program upon
the first occasion of such violation.
HHSC will keep my facts private if they were collected: If a court of law finds you guilty of having trafficked benefits for an
• By HHSC staff or contracted provider staff. aggregate amount of $500 or more, you will be permanently ineligible
• To find out if I can get state benefits. to participate in the Program upon the first occasion of such violation.
HHSC can share facts about me:
An individual found to have made a fraudulent statement or
• When needed for me to get state health-care benefits.
representation with respect to the identity or place of residence of the
• With phone and utility companies. They will find
out if my bill amount can be lowered. HHSC will individual in order to receive multiple SNAP benefits simultaneously
give them my name, address, and phone number. shall be ineligible to participate he program for a period of 10 years.

The same is true if anyone lets someone else use their Lone Star Card.
TANF Cash Help for Families
Child Support or Alimony Facts Anyone Tells or Gives HHSC
I agree to: HHSC uses the facts anyone tells or gives
• Let the state keep any child support or HHSC, including Social Security numbers to:
alimony money owed to anyone during the • Check if that person can get benefits.
time they get TANF. • Check that person's facts with computer matching programs and
• Let the state keep this money after TANF
credit report agencies.
benefits end, if the TANF amount anyone got
still needs to be paid off. • Make sure that person is following benefit program rules.
• Tell HHSC about money anyone gets. • Help other agencies check if that person can get other benefits.
• Work with HHSC to get this money; • Recover benefits that person wasn't supposed to get.
if I don't, I am breaking the law. • Share facts about that person: (1) with other state and federal agencies
(for example, the Texas Workforce Commission, the Social Security
The state will keep only the amount allowed by law. Administration, and the Internal Revenue Service); (2) with law
enforcement officials so they can find people on that person's benefits
If I Give False Information case (the household) who are wanted for fleeing the law; and (3) with
If I choose not to tell the truth, I might: federal, state, and private claims collecting agencies for food benefit
overpayment claims collection action.
• Be charged with and punished for a crime.
(This could include going to prison for up to (Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036.)
10 years or community supervision.)
• Have to repay benefits.
• Never get TANF again. More on next page

Social security number: H1010

Application for benefits 12/2023
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 Section W
Medicaid
Statement of If I Give False Information
If I don't help the state, my child
Understanding If I choose not to tell the truth, I might:
can get Medicaid, but I might not.
• Be charged with a crime. Identify who the child's other parent is.
• Have to repay benefits. Allow the state to keep any medical
The same is true if I let someone else use my support payments.
medical card or Medicaid ID. • I know I will be asked to cooperate with the
Giving Out Facts About Me agency that collects medical support from
an absent parent. If I think that cooperating
I agree to let Medicaid health care providers to collect medical support will harm me or
(doctors, drug stores, hospitals, etc.) give out my children, I can tell HHSC and I may not
any facts about me to HHSC. This will allow have to cooperate.
the providers to be paid by Medicaid.
Medical and Child Support Payments If I get Medicaid, HHSC will keep medical
service payments I can get from other sources,
Depending on my benefits case, the Attorney such as:
General (the state) might check that I am
getting the right amount of child or medical • My health insurance.
support payments and coverage. • Money I got because of injuries.
• If only my child gets Medicaid, I can • Money collected for me or my children
decide if I want the state to help get any by the Office of Attorney General.
Did you... payments and coverage we should get, I must tell HHSC about these sources.
but don't get right now. If I don't, I am breaking the law.
1. Sign and date
page 1 (if you have • If my child and I both get Medicaid, I must: HHSC will only keep the amount of medical
not already sent it in). Help the state get any payments and support and service payments allowed by law. I
coverage we should get, but don't right now. will work with HHSC to get these funds.
2. Include the "items
we need" listed
in the cover section. By signing below, I agree:
• To let HHSC and other state, federal, and local agencies check, share,
3. Sign and date and get facts about anyone on my benefits case (the household).
this page. • 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,
Sign here to show you agree: I may be subject to criminal prosecution.

Person applying or their authorized representative:

Sign here Date

Parent, guardian, or power of attorney for the person applying:

Sign here (you must give proof of this right) Phone Date
Witness (only needed if anyone above signed with an "X" or other mark):

Sign here Date

Printed name of witness

Social security number: H1010

Application for benefits 12/2023
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Addendum
Contact information

Miranda Kasper
Home address

Home address (line 1): .................................................................. 3701 Manor Ln

City: ............................................................................................... Dickinson

State: .............................................................................................. Texas

ZIP: ................................................................................................ 77539

County: .......................................................................................... Galveston

Mailing address

Mail address (line 1): .................................................................... PO Box 3073

City: ............................................................................................... Texas City

State: .............................................................................................. Texas

ZIP: ................................................................................................ 77592

County: .......................................................................................... Galveston

Language for letters and forms

Language for letters and forms we send you: ................................ English

Benefits for this person

Miranda Kasper
Benefit: ........................................................................................... Adult who isn't taking care of a child

Benefit: ........................................................................................... SNAP food benefits

Benefit: ........................................................................................... Healthy Texas Women

Page 1
Addendum
School

Miranda Kasper
Date this person plans to graduate: ...............................................

Tax return status

Miranda Kasper
Do you plan to file a federal income tax return next year? ........... No

Facts about the people you will claim

How is this person related to you? ................................................

Facts about the people who will claim you

Will someone claim you on their tax return? ................................ No

How is this person related to you? ................................................

Money you expect to get

Miranda Kasper
Total amount of money this person expects to get this year: ........ $0.00

Total amount of money this person expects to get next year: ....... $0.00

Has this person ever gotten health-care services or a referral from

either: (1) the Indian Health Service, (2) a tribal health program,
or (3) an urban Indian health program? ........................................ No
Is this person able to get health-care services or a referral from
either: (1) the Indian Health Service, (2) a tribal health program,
or (3) an urban Indian health program? ........................................ No

Other questions (Agency use only)

Have you been helped by an assister organization? ...................... No

Page 2
Addendum
Did this person ask to apply for health-care benefits for an adult
who isn’t taking care of a child? ................................................... Yes
Do you agree to allow the agency to renew your health coverage
in future years? .............................................................................. Yes - for 5 years
Does any child on this application have a parent living outside
of the home? .................................................................................. No

Individual Information (Agency use only)

Miranda Kasper
Social security number: ................................................................. 220-41-6800

Did this person ask to apply for health-care benefits for an adult
who isn’t taking care of a child? ................................................... Yes

Did this person ask to apply for health-care benefits for people
who were in foster care? ................................................................ No
Foster care

Was client in Foster care? ............................................................. No

Page 3
 Healthy Texas Women Application Form
The Healthy Texas Women program offers services such as woman's health exams,
health screenings and birth control.

Fill in facts about yourself - the woman who is applying for benefits
First Name * Last Name * MI Date of Birth (mm/dd/yyyy) Social Security number Agency Use Only
Miranda Kasper 08/18/1994 220-41-6800 Date Received

Home Address - Street * City * ZIP Code County

, Texas
3701 Manor Ln Dickinson 77539 Galveston
Fill in mailing address below if it's different from your home address. If you fill in a mailing address, we will send letters about your case there and not to your home.
Mailing Address – Street City State ZIP Code County
PO Box 3073 Texas City TX 77592 Galveston
Phone number we can call if we need to talk about your case or coverage. Ethnicity (optional)
Area code and phone number Hispanic/Latino ■ Not Hispanic
If you're not Hispanic, what race are you? (You don't have to answer.)
American Indian/Alaska Native Black/African American ■ White Asian Native Hawaiian/Pacific Islander Unknown

Are you pregnant? .............................................................................................. Yes No How many babies Due date

Is this your first pregnancy? ............................................................................... Yes No

When did the pregnancy end?

Were you pregnant during the last 12 months? ................................................................................................... Yes ■ No

Do you plan to file a federal income tax return NEXT YEAR? ................................................................................................................................... Yes No
(You can still apply for health insurance even if you don't file a federal income tax return.
Name of Spouse
Will you file jointly with a spouse? ............................................. Yes No

Will you claim any dependents on your tax return? ............... Yes No

List of name(s) of dependents.

Name of tax filer Relationship

Will you be claimed as a dependent on someones tax return? .... Yes No

Are you a U.S. citizen? .......... ■ Yes No If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? Yes No

Immigration document type Document ID number

Are you or your spouse or parent, an active-duty member Are you, or your spouse or parent, a veteran of the U.S.
of the U.S. military? .......................................................... Yes ■ No military? ............................................................................ Yes No

Do you want help paying for medical bills from the past 3 months? ........ Yes No Are you a full-time strudent? ............................ Yes ■ No

Were you in foster care at age 18 or older? ............................................. Yes ■ No Which state?..........................................

Tell us about everyone who lives in your home.

Date of Birth
Name (First, MI, Last) Social Security number* Sex* Race* Relationship to you
(mm/dd/yyyy)

Form T-H1867 Page 1

March 2021
 Current Job & Income Information
Your job may take money out of your check before taxes for retirement savings, medical insurance premiums or health savings accounts, dependent care expenses,
commuter expenses or life insurance premiums. These are pretax contributions.
Name of person who got money from a job
Employed Self-employed

Employer name and address Employer phone number

,
Wages/tips (before taxes) How often are you paid? Average hours worked each WEEK

Total amount of your pretax contributions per pay period How often is it contributed? Date contributed

If self-employed answer Type of work How much net income (profits once
the following questions: business expenses are paid) will you get
from this self-emploment this month?

Other income this month

Amount paid
Income How often?
or given

Deductions

Amount paid
Deduction How often?
or given

Health Coverage
Name of insured person
Employer insurance

Name of health insurance Policy number Coverage start date Coverage end date

Who pays the premium?

Amount you pay each month to cover your child(ren)
on this insurance? ...........................................................

Do you have health insurance that covers family planning services? ................................................................................................................................... Yes No
If yes: If we file a claim on your health insurance, will it cause you physical, emotional or other harm from your spouse, parents or other person?..... Yes No
o If yes: Tell us why filing a claim with your health insurance would cause you harm. If you need to use extra pages, make sure each page has your name and Social Security number.

If you are age 15, 16, or 17: A parent or legal guardian must apply for you. Tell us about one or both of your parents or your legal guardian here; they will be able to apply and
renew these services for you and manage the YourTexasBenefits.com account for you.

Date of Birth Parent or Legal Guardian

Name (First, MI, Last) Social Security number* Sex
(mm/dd/yyyy) (pick one)

Parent Legal Guardian

Parent

Form T-H1867 Page 2

March 2021
 For pregnant Individual 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
immunization 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.
Name of pregnant individual Language you prefer to be contacted in

(If contacted by cellular telephone, the call may be autodialed or prerecorded, and your carrier's usage rates may apply.)
By telephone Telephone number Cellular telephone number
(Carrier message and
data rates my apply)
By text message
E-mail address
By e-mail

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 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:
o laws that protect information on people who apply for or receive Medicaid (42 CFR part 431, subpart F);
o laws about the privacy and safety of personally identifiable information (45 CFR §155.260(f)); and
o 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.
Authorized representative (first, middle, last) Phone number Address

Organization name Organization ID number City State Zip Code

By signing this, I agree and understand that:

● The facts I give on this form can be used to find out if I, or the person applying, can be in the Healthy Texas Women program. The facts given on this form will be checked
by the Texas Health and Human Services Commission or other state agencies.
● The facts I give 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 pay for services.

Signature of person renewing services Date Signed Signature — Witness Date Signed
(If the person is age 15, 16, or 17, that person's (Required if applicant signed with an "X")
parent or legal guardian must sign here.)

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.
If you are not registered to vote where you live now, would you like to apply to register to vote here today? ...................................... Yes No
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, P.O. Box 12887 Austin, TX 78711. Phone 1-800-252-8683.

Agency Use Only: Voter Registration Status

Already registered Client declined Agency transmitted Client to mail Mailed to client Other

Agency staff signature:

Legal Information

Form T-H1867 Page 3

March 2021
 Social Security numbers: You need to give us a Social Security number (SSN) for only the person who is renewing services. If you don't have an SSN, we can help you
apply for one. Before you can get services, you must give us your SSN or be applying for one. We won't share your SSN with the Bureau of Citizenship and Immigration
Service (formerly INS). You won't have to give an SSN for anyone living in your home who is not asking for services. (42 U.S.C. §405(a)(2)(C)(i)

We use SSNs to check the amount of money you get (your income) and the income of people living in your home. We also use these numbers to verify facts about you
through other agencies (such as the Texas Workforce Commission, the Social Security Administration, the Internal Revenue Service, credit reporting agencies), and to get
back services you were not supposed to get. We may also share SSNs with phone and electric utility companies to help them find out if they can lower your bills. We also may
share SSNs with other groups to see if you can get other services or benefits based on need.

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.

Race, ethnicity and sex: We ask you to tell us about your race/ethnic background and sex (gender) but you don't have to give those facts to us. The same goes for people
living in your home. We use those facts to make sure services are approved without regard to race, color, or national origin. Whether you give us those facts or not, it will not
affect our decision on whether you can get services or how much you get in services or benefits.
Discrimination: In accordance with state law and regulation, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, or
religion. If you feel you have been discriminated against, you may contact HHSC Civil Rights by writing to: HHSC, Director, HHSC Civil Rights Office, 701 W. 51st St., Suite 104,
MC W-206, Austin, TX, 78751 . Or you can call 1-888-388-6332 (voice) or 1-512-438-2960 (TDD).
Legal guardian: A legal guardian is a person who has been appointed by a judge to take care of a child younger than age 18.
Immigration: You don't have to give us facts about immigration status for anyone living in your home who isn't asking for services. You can apply and get services or benefits for
eligible family members, even if you have people living in your home who are not eligible because of immigration status. If you or members of your family use Medicaid, the
Children's Health Insurance Program (CHIP) or SNAP food benefits, it will not affect you or your family members' immigration status or ability to get a green card. If you or your
family members use long-term institutional care, such as a nursing home, their immigration status could be affected. Talk to an agency that helps immigrants with legal questions
before you apply. Only refugees and people granted asylum can use any services or benefits, including cash assistance, without hurting their chances of getting a green card or
U.S. citizenship.

Items you can send as proof:

Immigration: Send copies of one of the following to show proof of immigration status: (1) an alien registration card or (2) a document from the Bureau for Citizenship and
Immigration Services (formerly INS).

Citizenship: Send copies of one of the following: (1) a U.S. passport, (2) a Certificate of Naturalization, or (3) a Certificate of U.S. Citizenship. If you don't have
one of those, send us copies of: (1) a birth certificate and (2) current driver's license with photo or ID card with photo. For people born in Texas, we might be able
to get the birth certificate electronically and you won't need to provide it. Call 2-1-1 or 1-877-541-7905 (after picking a language, press 2) to learn about other forms
that can show proof of citizenship. You don't have to prove citizenship for anyone living in your home who isn't asking for renewing services.

Money everyone in your home gets (income): Send copies such as: (1) pay stubs, (2) copy of checks, (3) statement from employer, (4) self-employment records, (5)
statement from the person who gives the money -- the statement should include that person's name, address, phone number, signature, and date.

Cost everyone in your home pays (expenses): Send proof such as: (1) copies of checks, (2) check stubs, (3) copy of district clerk record, (4) statement from the person you
pay -- the statement should include that person's name, address, phone number, signature, date and when and how often you are paid.

Copy all items of proof and fax them with this form to 1-866-993-9971 (toll-free).
Or you can mail this form and all items of proof to:
Healthy Texas Women
PO Box 149021
Austin, TX 78714-9021

Questions? Call us toll free at 2-1-1 or 1-877-541-7905 (after you pick a language, press 2). You can call Monday to Friday, 8 a.m. to 6 p.m. Central Time.

Form T-H1867 Page 4

March 2021
 Form H1805
SNAP Food Benefits: Your Rights and Program Rules May 2018

What can I buy with SNAP?

SNAP food benefits are used to buy food and garden seeds. Most grocery stores accept SNAP.
You can't use SNAP to:
• Buy tobacco.
• Buy alcoholic drinks.
• Buy things you can't eat or drink.
• Pay for food bills you already owe.

How will I get my SNAP benefits?

You will get a plastic card called the Lone Star Card. Every month your SNAP amount will be put in your Lone Star Card account.
You will use this card like a credit card at the cash register. To get help with your card, call 1-800-777-7328 (toll-free).

Can I get SNAP?

You might be able to get SNAP if the money you get (income) and the things you own are under a set limit.
Some things you own are not counted, for example:
• Your home
• Personal items
• Life insurance policies

How will I know how much I have in my SNAP account?

We will send you a letter telling you how much you will get each month. You can check your balance by logging into your account
at YourTexasBenefits.com or by calling the Lone Star Card help line at 1-800-777-7328 (toll-free).

How long will I get SNAP?

We will send you a letter telling you how long your benefit period is. Most adults age 18 to 49 who do not have a child in the home
can get SNAP benefits for only 3 months in a 3-year period. The benefit period can be longer if the adult works at least 20 hours a
week or is in an approved work program. Some might not have to work or be in a work program to get benefits, such as those
who have a disability or are pregnant.

How do I apply?
• Online: YourTexasBenefits.com.
• At a benefits office: To find a Texas Health and Human Services Commission (HHSC) benefits office near you, go to
YourTexasBenefits.com or call 2-1-1 (after you pick a language, press 1).
• Paper form (H1010): To get a form, you can either:
• Call 2-1-1 (after you pick a language, press 2);
• Call toll-free 1-877-541-7905 (after you pick a language, press 2); or
• Visit an HHSC benefits office.
Can someone else buy food for me?
You can get a Lone Star Card for another person. That person can use the card to buy food for you. You are responsible for what
that person buys with that card. If a card is lost or stolen, you must call us right away at 1-800-777-7328 (toll-free). We will not
replace any SNAP benefits used before you report the loss or theft of the card.

Your Rights
1. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies,
the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are
prohibited from discriminating 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.
 Form H1805
Page 2 / 05-2018

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.

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 mail at U.S. Department of Agriculture, Office of the Assistant
Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410, by fax (202) 690-7442 or email
at [email protected].

This institution is an equal opportunity provider.

You also can write to Texas Health and Human Services, Civil Rights Office, 701 W. 51st St., MC W206, Austin, Texas
78751, or call 1-888-388-6332.

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.

2. You can give us your application form in person or by mail. Another person can give us the form for you. You don't have to
go to an interview before giving us your form. You can give us the form the same day you get it. We must accept your form
if we can read your name and address, and it has been signed.
If you need help filling out the form or applying, we will help you.
3. You can request a paper or electronic copy of any application you filled out and gave to us, regardless of the original method
of submission by calling 211, visiting your local office, or logging in to your YourTexasBenefits.com account.

4. We must give you benefits within 30 days after you give us your application if you: (a) give us everything on time, and (b) we
find you meet SNAP program limits. Some people with very little money might get benefits the next workday after they apply.
5. You can talk to the office supervisor if: (a) you have questions that your caseworker can't answer, or (b) you disagree with a
decision your caseworker makes.
6. You can file a complaint by calling 2-1-1. If you don't get the help you need there, you can call the HHSC Office of the
Ombudsman at 1-877-787-8999. Both numbers are free to call.
7. If you think any action taken on your case is wrong, you can ask for a hearing to appeal. A hearing is a chance for you to tell
a hearing officer the reasons you think the action is wrong. The hearing officer will decide if the right action was taken.

8. A child who gets SNAP will get free school lunches. The child must: (a) go to a public or private school, and (b) be in grades
pre-school to high school. Contact your child's school if:
• You don't want your child to get free school lunches.
• You think your child should get free school lunches but doesn't.
• You have questions about the free school lunch program.
 Form H1805 .
Page 3 / 05-2018 .

Program Rules
1. Anyone who applies for or gets SNAP must tell the truth about their benefits case.
2. It is against the law for anyone to do or try to do any of the following:
• Trade, sell, or steal SNAP benefits or Lone Star Cards.
• Share their Lone Star Card PIN (password).
• Use Lone Star Cards that don't belong to them.
• Sell food they make with items bought with SNAP benefits.
• Buy items in refundable containers with SNAP benefits to get refunds and not use the items.
• Re-sell items bought with SNAP benefits.
3. Most people age 16 to 59 must follow work rules to get SNAP benefits. Work rules mean a person must look for a job or be
in an approved work program. If the person has a job, they can't quit without good cause. A person who doesn't follow the
work rules will be penalized.

If your SNAP case has more than one parent or caretaker with a child (age 17 or younger), you must decide which parent
or caretaker will be listed as the "primary wage earner." If you don't decide who will be the primary wage earner, HHSC will
decide for you. If the primary wage earner doesn't follow the work rules, everyone
on the SNAP case will be penalized. Penalties:
• 1st time: No SNAP benefits for 1 month or longer (until the person follows the rules).
• 2nd time: No SNAP benefits for 3 months or longer (until the person follows the rules).
• 3rd time: No SNAP benefits for 6 months or longer (until the person follows the rules).
4. You must tell us about changes to your case within 10 days of the change. We gave you a list that shows the changes we
need to know about (see Form H1019, Report of Change).
5. If you get more SNAP benefits than you should, you must pay them back.
6. If you move out of the state before using all the benefits in your account, you can use your Lone Star Card at stores
that accept SNAP benefits in other states.
7. These are the penalties for people who break SNAP rules on purpose:
• 1st time: Can't get SNAP for 1 year.
• 2nd time: Can't get SNAP for 2 years.
• 3rd time: Can never get SNAP again.
If a court of law decides you can't get benefits, the court will decide for how long.
8. If you have a felony drug conviction on or after September 1, 2015 and:
● If you don't follow parole or community supervision rules, you might not get SNAP for 2 years.
● If you get another felony drug conviction while you are getting SNAP, you can't ever get SNAP again.

If you have any questions, call 2-1-1.

 Forma H1805
Beneficios de comida del Programa SNAP: Mayo 2018
Sus derechos y las reglas del programa
¿Qué puedo comprar con el Programa SNAP?
Los beneficios de comida del Programa SNAP se usan para comprar alimentos y semillas para huertos. Casi todos los
supermercados aceptan el Programa SNAP.
Usted no puede usar el Programa SNAP para:
• Comprar tabaco.
• Comprar bebidas alcohólicas.
• Comprar cosas que no se puedan comer ni beber.
• Pagar cuentas de alimentos que ya debe.
¿Cómo recibo los beneficios del Programa SNAP?
Recibirá una tarjeta de plástico llamada tarjeta Lone Star. Cada mes la cantidad asignada por el programa SNAP se cargará a
su tarjeta Lone Star. Usted usará su tarjeta en la caja como una tarjeta de crédito. Para recibir ayuda con la tarjeta, llame al
1-800-777-7328 (sin costo).
¿Puedo recibir beneficios del Programa SNAP?
Usted podría recibir beneficios del Programa SNAP si el dinero que recibe (sus ingresos) y sus propiedades están por debajo
de un límite fijo.
Algunas de sus propiedades no se toman en cuenta, como por ejemplo:
• Su casa
• Artículos personales
• Pólizas de seguro de vida
¿Cómo sé cuánto tengo en la cuenta del Programa SNAP?
Le enviaremos una carta diciéndole cuánto recibirá cada mes. Puede revisar el saldo ingresando a su cuenta en
YourTexasBenefits.com o llamando a la línea de ayuda de la tarjeta Lone Star al 1-800-777-7328 (sin costo).
¿Por cuánto tiempo recibiré beneficios de comida del Programa SNAP?
Le enviaremos una carta diciéndole por cuánto tiempo puede cobrar beneficios. La mayoría de los adultos entre 18 y 49 años,
sin hijos en la casa, puede recibir beneficios del Programa SNAP por solo 3 meses en un periodo de 3 años. El periodo de
beneficios puede ser más largo si el adulto trabaja por lo menos 20 horas por semana o si está en un programa aprobado de
trabajo. Puede ser que algunos no tengan que trabajar ni estar en un programa de trabajo para recibir beneficios, como las
personas discapacitadas o las mujeres embarazadas.
¿Cómo solicito estos beneficios?
• En línea: YourTexasBenefits.com
• En una oficina de beneficios: Para encontrar una oficina de beneficios de la Comisión de Salud y Servicios Humanos
(HHSC) cerca de usted, vaya a YourTexasBenefits.com o llame al 2-1-1 (después de seleccionar un idioma, oprima el 1).
• Con una forma en papel (H1010): Para recibir una forma, tiene dos opciones:
• Llame al 2-1-1 (después de seleccionar un idioma, oprima el 2);
• Llame sin costo al 1-877-541-7905 (después de seleccionar un idioma, oprima el 2); o
• Visite una oficina de beneficios de la HHSC.
¿Puede otra persona comprarme los alimentos?
Usted puede obtener una tarjeta Lone Star para otra persona. Esa persona puede usar la tarjeta para comprarle los alimentos a
usted. Usted es responsable de lo que esa persona compre con esa tarjeta. Si se pierde o le roban la tarjeta, usted tiene que
llamarnos inmediatamente al 1-800-777-7328 (gratis). No le reembolsaremos por ningún beneficio del Programa SNAP usado
antes de avisar sobre la pérdida o el robo de la tarjeta.

Sus derechos
1. De conformidad con la Ley Federal de Derechos Civiles y los reglamentos y políticas de derechos civiles del Departamento
de Agricultura de los EE. UU. (USDA, por sus siglas en inglés), se prohíbe que el USDA, sus agencias, oficinas, empleados e
instituciones que participan o administran programas del USDA discriminen sobre la base de raza, color, nacionalidad, sexo,
credo religioso, discapacidad, edad, creencias políticas, o en represalia o venganza por actividades previas de derechos
civiles en algún programa o actividad realizados o financiados por el USDA.
 Forma H1805
Página 2 / 05-2018

Las personas con discapacidades que necesiten medios alternativos para la comunicación de la información del programa
(por ejemplo, sistema Braille, letras grandes, cintas de audio, lenguaje de señas americano, etc.), deben ponerse en contacto
con la agencia (estatal o local) en la que solicitaron los beneficios. Las personas sordas, con dificultades de audición o con
discapacidades del habla pueden comunicarse con el USDA por medio del Federal Relay Service [Servicio Federal de
Retransmisión] llamando al (800) 877-8339. Además, la información del programa se puede proporcionar en otros idiomas.

Para presentar una denuncia de discriminación, complete el Formulario de Denuncia de Discriminación del Programa del
USDA, (AD-3027) que está disponible en línea en:
http://www.ocio.usda.gov/sites/default/files/docs/2012/Spanish_Form_508_Compliant_6_8_12_0.pdf, y en cualquier oficina
del USDA, o bien escriba una carta dirigida al USDA e incluya en la carta toda la información solicitada en el formulario. Para
solicitar una copia del formulario de denuncia, llame al (866) 632-9992. Haga llegar su formulario lleno o carta al USDA por
correo a U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW,
Washington, D.C. 20250-9410, por fax (202) 690-7442, o correo electrónico a [email protected].

Esta institución es un proveedor que ofrece igualdad de oportunidades.

También puede comunicarse con la Oficina de Derechos Civiles de la HHS de Texas. Escriba a Salud y Servicios Humanos
de Texas, Civil Rights Office, 701 W. 51st St., MC W206, Austin, Texas 78751, o llame al 1-888-388-6332.

Para obtener información adicional relacionada con problemas con el Programa de Asistencia Nutricional Suplementaria
(SNAP, por sus siglas en inglés), las personas deben comunicarse con el número de línea directa de USDA SNAP Hotline al
(800) 221-5689, que también está disponible en español, o llame a los números de información/líneas directas de los estados
(haga clic en el vínculo para ver una lista de los números de las líneas directas de cada estado) que se encuentran en línea
en: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
2. Nos puede dar la solicitud en persona o la puede enviar por correo. Otra persona nos la puede entregar a nombre suyo. Usted
no tiene que ir a una entrevista antes de entregarnos la solicitud. Nos la puede dar el mismo día que la recibe. Tenemos que
aceptar la solicitud si su nombre y dirección se pueden leer, y si está firmada. Si necesita ayuda para llenar la solicitud,
podemos ayudarle.
3. Puede solicitor una copia impresa o electronica de cualquier solicitud que haya completado y nos haya entregado,
independientemente del metodo original de envoi, llamando al 211, visitando su oficina local o ingresando a su cuenta
YourTexasBenefits.com.
4. Tenemos que darle los beneficios dentro de 30 días después de recibir su solicitud, si usted: (a) nos da todo a tiempo y
(b) decidimos que usted satisface los límites del Programa SNAP.
Algunas personas con muy poco dinero podrían recibir beneficios el siguiente día laboral después de presentar la solicitud.
5. Puede hablar con el supervisor de la oficina si: (a) tiene preguntas que el trabajador de casos no puede contestar o (b) no está
de acuerdo con una decisión del trabajador de casos.
6. Puede presentar una queja llamando al 211. Si no le dan la ayuda que necesita, también puede llamar a la Oficina del
Ombudsman de la HHSC al 1-877-787-8999. Llamar a estos teléfonos es gratis.
7. Si cree que alguna acción tomada en su caso es incorrecta, puede pedir una audiencia para apelarla. Una audiencia es una
oportunidad para decirle al funcionario de audiencias las razones por las cuales cree que la acción es incorrecta. El
funcionario de audiencias decidirá si se tomó la acción correcta.
8. Un niño que recibe beneficios del Programa SNAP recibirá el almuerzo gratis en la escuela. El niño tiene que: (a) asistir a una
escuela pública o privada y (b) estar en cualquier grado desde el prekinder hasta la preparatoria.
Comuníquese con la escuela de su hijo si:
• No quiere que su hijo reciba el almuerzo gratis en la escuela.
• Cree que su hijo debe recibir el almuerzo gratis, pero no lo recibe.
• Tiene preguntas sobre el programa de almuerzo gratis.
 Forma H1805 .
Página 3 / 05-2018 .

Reglas del programa

1. Cualquier persona que solicite o reciba beneficios del SNAP tiene que decir la verdad sobre su caso de beneficios.

2. Es contra la ley que cualquier persona haga o trate de hacer una de las siguientes:
• Intercambiar, vender o robar beneficios del SNAP o de las tarjetas Lone Star.
• Compartir su número de PIN (contraseña) de la tarjeta Lone Star.
• Usar tarjetas Lone Star que no le pertenecen.
• Vender comida que preparen con artículos comprados con los beneficios del SNAP.
• Comprar artículos en recipientes reembolsables con los beneficios del SNAP para recibir reembolsos y no usar los
artículos.
• Revender artículos que compró con los beneficios de comida del SNAP.
3. La mayoría de las personas entre 16 y 59 años tiene que seguir las reglas de empleo para recibir beneficios del Programa
SNAP. Según las reglas de empleo, una persona tiene que buscar trabajo o estar en un programa aprobado de trabajo. Si la
persona tiene trabajo, no puede dejarlo sin tener un motivo justificado. La persona que no sigue las reglas de empleo será
sancionada.
Si en su caso del Programa SNAP hay más de un padre o cuidador con un niño (de 17 años o menos), usted tiene que decidir
cuál padre o cuidador aparecerá como el "principal sostén económico." Si no decide quién va a ser el principal sostén
económico, la HHSC decidirá por usted. Si el principal sostén económico no sigue las reglas de empleo, todas las personas
que estén en el caso del Programa SNAP serán sancionadas. Sanciones:
• 1.a vez: No recibirá beneficios del Programa SNAP por 1 mes o por más tiempo (hasta que la persona siga las reglas).
• 2.a vez: No recibirá beneficios del Programa SNAP por 3 meses o por más tiempo (hasta que la persona siga las
reglas).
• 3.a vez: No recibirá beneficios del Programa SNAP por 6 meses o por más tiempo (hasta que la persona siga las
reglas).
4. Usted tiene que decirnos sobre cambios en su caso dentro de 10 días después del cambio. Le dimos una lista que muestra los
cambios que necesitamos saber (vea la Forma H1019s, Informe de cambio).
5. Si recibe más beneficios del Programa SNAP de los que debería recibir, tiene que devolver el exceso.
6. Si se muda fuera del estado antes de usar todos los beneficios en su cuenta, puede usar la tarjeta Lone Star en otros estados
en los supermercados que acepten beneficios del Programa SNAP.
7. Estas son las sanciones que sufrirán las personas que intencionalmente violan las reglas del Programa SNAP:
• 1.a vez: No puede recibir beneficios del Programa SNAP por 1 año.
• 2.a vez: No puede recibir beneficios del Programa SNAP por 2 años.
• 3.a vez: Jamás volverá a recibir beneficios del Programa SNAP.
Si una corte decide que usted no puede recibir beneficios, la corte decidirá por cuánto tiempo.
8. Si usted ha sido declarado culpable de un delito grave relacionado con drogas del 10 de septiembre de 2015 en adelante, y:
• Si usted no cumple con las reglas de su libertad condicional o supervisión comunitaria, no podrá recibir beneficios de
SNAP por 2 años.
• Si es declarado culpable de otro delito grave relacionado con drogas mientras recibe beneficios de SNAP, no podrá
jamás volver a recibir beneficios de SNAP.

Si tiene alguna pregunta, llame al 211.