Form H1003 PDF Details

In order to ensure the accuracy of tax information submitted by individuals and businesses, the Internal Revenue Service has created Form H1003. This form is used to verify wage and salary information with the employer, as well as other sources of income. The IRS may also use this form to resolve discrepancies discovered during an audit. It is important to complete this form accurately and submit it on time, in order to avoid penalties and additional taxes.

This general report will let you determine the time it'll take you to complete form h1003, how many pages it has, and a handful of additional specific details about the form.

QuestionAnswer
Form NameForm H1003
Form Length1 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out27 sec
Other nameshhsc form h1003 form, your texas benefits form h1003, h1003 pdf, texas form h1003

Form Preview Example

Form H1003

04-2015-E

Appointment of an Authorized Representative

to Allow Another Person to Act for You

If you want, you can give someone the right to act for you (an authorized representative).

That person can:

•Give and get facts for this application.

•Take any action needed for the application process. This includes appealing an HHSC decision.

•Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.

•Take any action needed to get benefits. This includes reporting changes and renewing benefits.

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 www.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 this form.

1. Contact Information

Client or Applicant Name

Case Number

 

 

Name of person who can act for you (authorized representative)

Organization

 

 

Address of person who can act for you (authorized representative)

 

 

 

Telephone number with area code of person who can act for you (authorized representative)

 

 

 

2. The authorized representative is your:

Power of attorney

Court-appointed guardian (give end date):

Other (tell us about your relationship):

3.Sign below if you want the person you are listing on this form to be your authorized representative.

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.

Signature — Person who agrees to be the authorized representative

Date

(This person must be age 18 or older.)

 

Signature — Client or Applicant

Date

How to Edit Form H1003 Online for Free

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stage 1 to writing hhsc form 1003

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hhsc form 1003 SignatureClientorApplicant, and Date blanks to insert

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