Form H1010 – Fill Out and Use This PDF

SNAP Food Benefits

(This used to be called Food Stamps.) Helps buy food for good health. Some people might get help the next work day.

TANF Cash Help for Families

TANF: Temporary Assistance for Needy Families

Helps pay for things like food, clothing, and housing.

•TANF: Helps families with children

age 18 and younger pay for basic needs. TANF gives monthly cash payments.

•One-Time TANF: Helps families with children age 18 and younger in crisis. Crises include losing a job, not finding a job, losing a home, or a medical emergency. This help is given only once every 12 months.

•One-Time TANF Grandparent: Helps grandparents caring for a child who gets TANF.

Medicaid and CHIP

Helps with medical bills such as bills for doctors, hospitals, and medicines.

People who can get health-care benefits are:

•Children age 20 and younger who live with you.

•Pregnant women.

•Adults who either: (1) are caring for

a child in their home or (2) were in foster care at age 18 or older.

If you want to apply for Medicaid for the Elderly and People with Disabilities, you need a different form. To get that form, call 2-1-1 (after you pick a language, press 2).

All phone and fax numbers on this form are free to call. If you are deaf, hard of hearing, or speech impaired, you can call any number by calling 7-1-1 or 1-800-735-2989.

How to Apply

What to do:

1.Fill out this form.

2.Sign and date pages 1 and 18.

3.Send “Items we need.” See pages C and D.

How to send it:

Mail: HHSC, PO Box 149024, Austin, TX 78714-9968 Fax: 1-877-447-2839. If your form is 2-sided, fax both sides. In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 (after picking a language, press 1).

YourTexasBenefits.com

On this website you can:

•Apply for benefits.

•Find out if you should apply for benefits.

•Report changes.

•Upload items we need from you.

•Renew benefits.

Questions about this form or about benefits

•Go to YourTexasBenefits.com. or

•Call 2-1-1 (if you can’t connect, call 1-877-541-7905).

After you pick a language, press 2 to:

–Ask questions about this form.

–Find where to get help filling out this form.

–Check the status of this form.

–Ask questions about benefit programs.

Report waste, fraud, and abuse

Helpful Tips

•There are tips in the left side of each page. They can help you save time.

•Sign and date pages 1 and 18.

•Send “Items we need.” See pages C and D.

These pictures tell you what sections you need to fill out.

For example, if you see this:

It means that only people applying for SNAP food benefits need to fill out that section.

If you think anyone is misusing HHSC benefits, call 1-800-436-6184.

How to file a complaint

If you have a complaint, first try talking to your benefits advisor or their supervisor. If you still need help, call 1-877-787-8999.

Services in your area

Do you need help finding services? Call 2-1-1 (if you can’t connect, call 1-877-541-7905).

After you pick a language, press 1.

Texas Workforce Network

Are you looking for work?

You can get help:

•Applying for a job.

•Finding a job.

Call 2-1-1 to find a Texas

Workforce Center.

Family Planning

Do you need help with family planning? Men and women can get help with:

•Birth control supplies.

•Other health care. Call 2-1-1 to find a clinic.

Women age 15 to 44 who can’t get Medicaid or CHIP might be able to get services in the Healthy Texas Women program. A parent or legal guardian must apply for young women age 15 to 17. To learn more, go to HealthyTexasWomen.org or call 1-866-993-9972.

Family Violence Program

Are you afraid for your children’s or your safety? You can get help:

•Getting a ride to a safe place.

•Finding shelter, legal help, and a job.

•Getting counseling.

Call the hotline anytime at

1-800-799-7233 (1-800-799-SAFE).

Adult Education and Family Literacy Program

Do you want help learning to

read or getting a GED? Do you need help with job skills? Or learning to speak English?

Call 1-800-441-7323 (1-800-441-READ).

Women, Infants

and Children program (WIC)

Are you pregnant or a new mother? You can get help:

•Getting food for you and your children.

•Getting vaccines.

Call 1-800-942-3678.

Alcohol and Drug Abuse

Prevention Program

Do you or someone you know

want to stop using alcohol or drugs? You can get help:

•Quitting.

•Dealing with a crisis.

•Keeping others from using drugs or alcohol.

Call 1-877-966-3784 (1-877-9-NO DRUG).

Health Insurance Premium Payment Program (HIPP)

Do you need help paying for your health insurance?

Call 1-800-440-0493.

Or write: Texas Health and Human Services Commission TMHP-HIPP, PO Box 201120 Austin, Texas 78720-1120

Important Information for Former Military Service Members

Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard may be eligible for additional benefits and services. For more information, please visit the Texas Veterans Portal at https://veterans.portal.texas.gov.

•Identity (proof of who you are) – Current driver’s license or Department of Public Safety ID card.

If a person has the right to act for you (as your authorized representative), that person also needs to give proof of identity.

•Immigration status – Resident card (I-551), arrival/ departure form (I-94). Or papers from the U.S. Citizenship and Immigration Services. We need copies of the front and back of these forms.

•Legal representative (a person who has the right to act for you on legal issues) – Power of attorney papers, guardianship order, court order, or similar court documents.

•Veterans benefits, workers’ compensation, or unemployment – Award letter or pay stubs.

•Social Security, Supplemental Security

Income (SSI), or pension benefits – Award letter or pay stubs.

•Military service – Current Military ID (Form DD-2), military orders, or separation papers (Form DD-214).

•Loans and gifts (includes someone paying

bills for you) – Loan agreements or statement from the person giving you money or paying your bills. Must show that person’s name, address, phone number, and signature.

•Residence (proof you live in Texas) – Utility bill, driver’s license, Texas Department of Public Safety ID, rent receipt, letter from landlord (can’t be

a relative).

•Proof of income from your job – Last 3 pay stubs or paychecks, a statement from your employer, or self-employment records.

•Bank accounts – The most current statement for all accounts.

•Medical costs – Bills, receipts, or statements from health-care providers (doctors, hospitals, drug stores, etc.). These items should show costs you have now and costs you expect in the future.

•Rent or mortgage costs – Recent checks, check stubs, or statement from the mortgage bank or landlord. Renters also need to give the landlord’s name, address, and phone number.

•Dependent care expenses – Receipts, canceled checks, or a signed statement from the person you pay. A signed statement must show when and how much you pay.

•Child support anyone pays – Court papers that show what you must pay for child support. For example: divorce decree, court order, or district clerk record.

•Child support anyone gets – District clerk record. Or letter from the parent who pays showing how much, how often and the date it is usually paid. The letter must have the name, address, phone number, and signature of the parent who pays.

•Proof of income from your job – Last 3 pay stubs or paychecks, a statement from your employer,

or self-employment records.

•Bank accounts – Most current statement for all accounts.

•Proof a child is related to you – Legal birth, hospital, or baptismal certificate.

•Citizenship – U.S. passport, Certificate of Naturalization, U.S. birth certificate (copies of the front and back), hospital record of birth, or Medicare card. If you were born in Texas, we might be able to look up your birth record.

•Child’s vaccines – Vaccine records for each child.

•Proof a child lives with you – A signed statement from your landlord or a non-relative neighbor that includes his or her name, address, and phone number.

•Child support anyone pays – Court papers that show what you must pay for child support. For example: divorce decree, court order, or district clerk record.

•Child support anyone gets – District clerk record. Or letter from the parent who pays showing how much, how often and the date it is usually paid. The letter must have the name, address, phone number, and signature of the parent who pays.

•Health insurance – Copy of the front and back of the insurance card or policy.

•Proof of income from your job – One pay stub or paycheck from the last 60 days, a statement from your employer, or self-employment records.

•Medical costs – Bills or statements from health-care providers (doctors, drug stores, etc.) from the past 3 months. We only need these items if you haven’t already paid for these services.

•Citizenship – U.S. passport, Certificate of Naturalization, U.S. birth certificate (copies of the front and back), hospital record of birth, or Medicare card. If you were born in Texas, we might be able to look up your birth record.

•Proof of income from your job – Last 3 pay stubs or paychecks, a statement from your employer, self-employment records, or last year’s tax return.

•Medical costs – Bills or statements from health-care providers (doctors, hospitals, drug stores, etc.) from the past 3 months. We only need these items if you haven’t already paid for these services.

•Citizenship – U.S. passport, Certificate of Naturalization, U.S. birth certificate (copies of the front and back), hospital record of birth, or Medicare card. If you were born in Texas, we might be able to look up your birth record.

Your Texas Benefits: Form

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

Fill in the circles () like this

Section A

Your Facts

If you're applying to get SNAP food benefits, the first month's amount will be based on the date we get pages 1 and 2.

Other benefits also are based on when we get pages 1 and 2.

If you return only pages 1 and 2 now, you still need to fill out pages 3 to 18 before you can get benefits.

You have the right to file this form immediately if it has your name, address, and signature.

Section B

Food Benefits

This section is only for people applying for

SNAP

food benefits.

Find out how to return your form: See page 3.

You might be able to get SNAP food benefits the next work day if you:

•Are migrant or seasonal farm worker,

•Have $100 or less in available cash and bank account and expect to earn less than $150 this month, or

•Have costs for housing or utilities that are more than your cash, bank accounts and the income you expect for the month.

Answer them for everyone living in your home.