Form H1010 – Fill Out and Use This PDF

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Form H1010 – Fill Out and Use This PDF

Form H1010 is an important document required to be filled out by patients, taxpayers, or those in the armed forces. It contains personal and contact information pertaining to one's employment status, residential location, and identification details. The digitalized version of Form H1010 is submitted electronically to the respective institutions for verification. This form is often used as a benchmark when conferring privileges concerning payment or taxes from policymakers. An adequately filled Form H1010 with corresponding biographical accounts ensure accuracy and convenience when recording transactional activities processed through governmental channels.

Form H1010 PDF Details

Form H1010 is an information return filed by a fiduciary with the Internal Revenue Service (IRS). The form is used to report the receipt and distribution of certain trust and estate income. This includes distributions from revocable trusts, irrevocable trusts, estates, and qualified retirement plans. The deadline for filing Form H1010 is April 15th of the following year. Failing to file this form on time can result in significant penalties. For more information on Form H1010, please contact your tax professional.

Question	Answer
Form Name	Form H1010
Form Length	32 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	8 min
Other names	tx application assistance, form h1010, benefits your applying, form h1010r

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Your Texas Benefits: Getting Started

SNAP Food Benefits

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

TANF Cash Help for Families

TANF: Temporary Assistance for Needy Families

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

•TANF: Helps families with children

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

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

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

Medicaid and CHIP

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

People who can get health-care benefits are:

•Children age 20 and younger who live with you.

•Pregnant women.

•Adults who either: (1) are caring for

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

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

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

How to Apply

What to do:

1.Fill out this form.

2.Sign and date pages 1 and 18.

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

How to send it:

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

YourTexasBenefits.com

On this website you can:

•Apply for benefits.

•Find out if you should apply for benefits.

•Report changes.

•Upload items we need from you.

•Renew benefits.

Don’t send this page with your form. Keep for your records. Page A

Texas Health and Human Services Commission (HHSC)

Questions about this form or about benefits

•Go to YourTexasBenefits.com. or

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

After you pick a language, press 2 to:

–Ask questions about this form.

–Find where to get help filling out this form.

–Check the status of this form.

–Ask questions about benefit programs.

Report waste, fraud, and abuse

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.

Help you can get without filling out this form

Services in your area

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

After you pick a language, press 1.

Texas Workforce Network

Are you looking for work?

You can get help:

•Applying for a job.

•Finding a job.

Call 2-1-1 to find a Texas

Workforce Center.

Family 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.

Don’t send this page with your form. Keep for your records. Page B

Items we need from anyone on your case

Look below and on the next page for items we might need from you. If you bring or send copies

of these items with your application, it might help us. If you send any items to us, send only copies. Keep the originals for your records.

We only need items that apply to anyone on your case. For example, if no one has a bank account, we do not need bank statements.

If you are applying for

Any Benefit Program

bringing or sending copies of items that apply to anyone on your case might help us review it faster.

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

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

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

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

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

•Social Security, Supplemental Security

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

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

•Loans and gifts (includes someone paying

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

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

a relative).

If you are applying for

SNAP food benefits

bringing or sending copies of items that apply to anyone on your case might help us review it faster.

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

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

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

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

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

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

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

	More on the
To get SNAP, a person must be a U.S. citizen or legal resident.	next page

If you need help getting these items, let us know.

Don’t send this page with your form. Keep for your records. Page C

More items we need from you

If you are applying for

TANF Cash Help for Families

bringing or sending copies of items that apply to anyone on your case might help us review it faster.

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

or self-employment records.

•Bank accounts – Most current statement for all accounts.

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

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

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

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

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

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

If you are applying for

CHIP or Children’s Medicaid

bringing or sending copies of items that apply to anyone on your case might help us review it faster.

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

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

If you are applying for

Medicaid for a Pregnant Woman or an Adult

bringing or sending copies of items that apply to anyone on your case might help us review it faster.

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

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

If you need help getting these items, let us know.

Don’t send this page with your form. Keep for your records. Page D

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.

Mark the benefits anyone on your case is applying for:

Medicaid or CHIP:

Children

Adult Caring for a Child

SNAP Food

TANF Cash Help

Adult not Caring for a Child

Benefits

for Families

Pregnant Women

Person 1: contact person or head of household

First name

Middle name

Last name

Social Security number

Birth date (month/day/year)

Mailing address

City

State

Zip

( ) -

( )

Home phone

Cell or daytime phone

Home address

County

City

State

Zip

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

•Are migrant or seasonal farm worker,

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

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

Answer them for everyone living in your home.

1. Is anyone in the home a migrant worker or seasonal farm worker?

................

Yes

......2. Does anyone in the home have money in the bank or cash?

Yes

Amount

3. Does anyone in the home expect to receive money this

month? (This includes money you get from jobs, child

Yes

Amount

support, social security and unemployment)

4. Does anyone in the home pay costs for housing and utilities?

(This includes rent, mortgage, water, gas, electric, sewage,

Yes

Amount

trash, phone and property tax)

Sign here (or have someone with the right to act for you sign)

Date

More on page 2

Application for benefits

H1010

11/2019

Texas Health and Human Services Commission

Page 1

Section C

Pregnant

Women

This section is only for people applying for health-care benefits.

Is anyone in your home pregnant?	.................................................	Yes	No


If yes, who?		Number of
If yes, who?		Number of
Is this your first pregnancy?		babies expected
Is this your first pregnancy?	No

Due date / /

What is the first and last name of the unborn child's father?

First name

Last name

Section D

Military

Service

This section is only for people applying Medicaid or CHIP.

Section E

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

•U.S. Armed Forces

•National Guard

•Reserves

• State Military Forces

Yes

If yes, who?

1.Most people applying for benefits must be interviewed. We often interview people on the phone.

It helps to know if any of the reasons below make it hard for you to get to a benefits office:

Interview Help

•You live more than 30 miles from the closest benefits office.

•You can't get a ride.

•The weather is bad.

•You are sick.

•Your work or training hours don't allow you to get to a benefits office when it's open.

•You can't travel because you are age 60 or older, or you have a disability.

•You are a victim of family violence.

•You take care of someone in your home.

Do any of the reasons above apply to you?	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?

Agency Use Only

Expedite?	Yes	No
Expedite?	Yes	No

Date received:		Screened by:
Date received:		Screened by:
Date screened:		Case:

Social Security number:

	H1010
Application for benefits	11/2019
Texas Health and Human Services Commission	Page 2

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

Section F

Contacting You

Person 1: Contact Person or Head of Household

First nameMiddle name Last name

Social Security number

Birth date (month/day/year)

E-mail

Are you applying for benefits for yourself or a child?

........................

Yes

If yes, give your facts below:

Section G

Person 1

Mark the benefits Person 1 is applying for:

SNAP Food Benefits

TANF Cash Help for Families:

TANF

One-Time TANF

Grandparent

Medicaid or CHIP for:

Children

Adult caring for a child

Adult not caring for a child

Pregnant women

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
Separated	Widowed	Plan to stay in Texas?	Yes	No

	Male	Female		Hispanic or Latino?		Yes	No
Optional
Questions	Mark one or more:				American Indian or Alaska Native		Asian
					American Indian or Alaska Native		Asian
	Black or African-American				Native Hawaiian or Pacific Islander		White
Are you going to school?....		Yes	No		If yes, are you going full-time?	Yes	No

Are you a U.S. citizen? If no, give facts below.	......................................	Yes	No

Are you a refugee or legally admitted immigrant?	.......................................	Yes	No

If you have a sponsor, write your sponsor's name			Date you entered the U.S. (month/day/year)
Are you registered with the U.S.


Citizenship and Immigration Services?
Citizenship and Immigration Services?	Yes	No Immigrant registration number
	Yes	No Immigrant registration number

Return this completed form by fax, mail, or in person:	If you are applying for Medicaid or CHIP:
Fax: 1-877-447-2839	You also must fill out the attached form titled
Mail: HHSC, PO Box 149024,	"Applying for or renewing Medicaid or CHIP"
Austin, TX 78714-9968
In person: Call 2-1-1 to find an HHSC benefits office near you.

Application for benefits

Texas Health and Human Services Commission

H1010

11/2019

Page 3

Section H	Person 2: adult or child applying, spouse of person applying, or parent living with a child who is a 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
Mark the benefits	This person's relationship to you				retirement, list the number here: Social Security claim #					Railroad retirement #
Mark the benefits
Person 2 is applying for:	Married	Single	Divorced				Male	Female		Hispanic or Latino?
SNAP Food Benefits	Married	Single	Divorced				Male	Female		Hispanic or Latino?
TANF Cash Help	Separated	Widowed				Optional	Mark one or more:		Black or African-American
for Families:	Live in Texas?					No Questions
TANF	Live in Texas?			Yes		No Questions	American Indian or Alaska Native				Asian
One-Time TANF	Plan to stay in Texas?						Native Hawaiian or Pacific Islander				White
One-Time TANF	Plan to stay in Texas?			Yes		No	Native Hawaiian or Pacific Islander				White
Grandparent

	Is this person going to school? Yes No If yes, is this person going full-time?	Yes	No

Medicaid or CHIP for:	Is this person a U.S. citizen? If no, give facts below	Yes	No

Children
Adult caring for a child	Is this person a refugee or legally admitted immigrant?	.................................	Yes	No
Adult not caring for a		/	/
child		/	/
Pregnant women

If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)

If you are applying

Is this person registered with the U.S.

Yes

Citizenship and Immigration Services?...

for Medicaid or

Immigrant registration number

CHIP:

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

You also must fill out

the attached form

titled

“Applying for

First name

Middle name

Last name

or renewing Medicaid

or CHIP?”

Social Security number

Birth date (month/day/year)

If this person gets money from

Social Security or railroad

Mark the benefits

This person's relationship to you

retirement, list the number here: Social Security claim #

Railroad retirement #

Person 3 is applying for:

Married

Single

Divorced

Male

Female

Hispanic or Latino?

SNAP Food Benefits

TANF Cash Help

Separated

Widowed

Optional

Mark one or more:

Black or African-American

for Families:

Live in Texas?

No Questions

TANF

Yes

American Indian or Alaska Native

Asian

One-Time TANF

Plan to stay in Texas?

Native Hawaiian or Pacific Islander

White

One-Time TANF

Yes

Grandparent

Yes

No If yes, is this person going full-time?

Is this person going to school?

Yes

Medicaid or CHIP for:

Is this person a U.S. citizen? If no, give facts below

................................

Yes

Children

Adult caring for a child

Is this person a refugee or legally admitted immigrant?

.................................

Yes

Adult not caring for a

child

Pregnant women

If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)

Is this person registered with the U.S.


Citizenship and Immigration Services?...
Citizenship and Immigration Services?...	Yes No Immigrant registration number
	Yes No Immigrant registration number
		Application for benefits	H1010
		Application for benefits	11/2019
Texas Health and Human Services Commission			11/2019
Texas Health and Human Services Commission			Page 4
			Page 4

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
Person 4 is applying for:	Married	Single	Divorced			Male	Female	Hispanic or Latino?
SNAP Food Benefits	Married	Single	Divorced			Male	Female	Hispanic or Latino?
SNAP Food Benefits
TANF Cash Help	Separated	Widowed			Optional	Mark one or more:		Black or African-American
for Families:	Live in Texas?		Yes	No	Questions	American Indian or Alaska Native				Asian
TANF
One-Time TANF	Plan to stay in Texas?		Yes	No		Native Hawaiian or Pacific Islander				White
One-Time TANF	Plan to stay in Texas?		Yes	No		Native Hawaiian or Pacific Islander				White
One-Time TANF
Grandparent	Is this person going to school?			Yes	No If yes, is this person going full-time?				Yes	No
	Is this person going to school?			Yes	No If yes, is this person going full-time?				Yes	No
Medicaid or CHIP for:	Is this person a U.S. citizen? If no, give facts below					................................			Yes	No
Children	Is this person a refugee or legally admitted immigrant?					................................			Yes	No
Adult caring for a child	Is this person a refugee or legally admitted immigrant?					................................			Yes	No
Adult not caring for a							/	/
child							/	/
Pregnant women	If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)

If you are applying

Is this person registered with the U.S.

Yes

for Medicaid or

Citizenship and Immigration Services?...

Immigrant registration number

CHIP:

You also must fill out

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

the attached form

titled

“Applying for

First name

Middle name

Last name

or renewing Medicaid

or CHIP?”

Social Security number

Birth date (month/day/year)

If this person gets money from

Mark the benefits

Social Security or railroad

retirement, list the number here: Social Security claim #

Person 5 is applying for:

This person's relationship to you

Railroad retirement #

SNAP Food Benefits
TANF Cash Help	Married	Single	Divorced			Male	Female	Hispanic or Latino?
TANF Cash Help
for Families:	Separated	Widowed			Optional	Mark one or more:		Black or African-American
TANF	Separated	Widowed			Optional	Mark one or more:		Black or African-American
TANF					Questions
One-Time TANF	Live in Texas?		Yes	No	Questions	American Indian or Alaska Native				Asian
One-Time TANF	Live in Texas?		Yes	No		American Indian or Alaska Native				Asian
One-Time TANF
Grandparent	Plan to stay in Texas?		Yes	No		Native Hawaiian or Pacific Islander				White
Medicaid or CHIP for:	Is this person going to school?			Yes	No If yes, is this person going full-time?				Yes	No
Medicaid or CHIP for:
Children	Is this person a U.S. citizen? If no, give facts below					................................			Yes	No
Adult caring for a child	Is this person a U.S. citizen? If no, give facts below					................................			Yes	No
Adult not caring for a	Is this person a refugee or legally admitted immigrant?					................................			Yes	No
child	Is this person a refugee or legally admitted immigrant?					................................			Yes	No
child							/	/
Pregnant women							/	/
Pregnant women

	If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)
If more than 5
	Is this person registered with the U.S.

people are applying		Yes	No
	Citizenship and Immigration Services?...
	Citizenship and Immigration Services?...			Immigrant registration number
for benefits, add				Immigrant registration number
for benefits, add					H1010
more pages with the			Application for benefits		H1010
more pages with the					11/2019
same facts.					11/2019
same facts.	Texas Health and Human Services Commission				Page 5
	Texas Health and Human Services Commission				Page 5

Section I

1st child's name:

More Facts About Children Age 18 or Younger

FATHER

Father's first and last name

- -

Father's Social Security number

/ /

Father's birth date (mm/dd/yyyy)

() - Father's phone

This section is only for children applying for TANF.

Time Saving Tip

You only need to give facts for each father and mother one time.

If a child has the same mother or father as another child, you can write something like “same as 1st child” where the parent's name would go.

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

Mother's Social Security number

Mother's birth date (mm/dd/yyyy)

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

2nd child's name:

Are you afraid that giving facts about the child's other parent might put you or your children in danger?

FATHER

Father's first and last name

- -

Father's Social Security number

/ /

Father's birth date (mm/dd/yyyy)

() - Father's phone

You might not have to help or cooperate with the Office of Attorney General to collect child or medical support if you are afraid. You can ask not to give these facts by:

•Telling your benefits advisor (or designated representative) reasons why this might put you or your children in danger.

•Signing the Good Cause request form. (Your benefits advisor has this form.)

Father's mailing address	City	State	Zip
Father is: In home Out of home	Deceased	Employer
Father is: In home Out of home	Deceased	Employer




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

MOTHER	-	-	/	/
MOTHER	Mother's Social Security number		Mother's birth date (mm/dd/yyyy)
	Mother's Social Security number		Mother's birth date (mm/dd/yyyy)

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

Application for benefits

H1010

11/2019

Texas Health and Human Services Commission

Page 6

Section I

3rd child's name:

More Facts About Children Age 18 or Younger

(continued)

FATHER

Father's first and last name

- -

Father's Social Security number

/ /

Father's birth date (mm/dd/yyyy)

() - 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

Mother's Social Security number

Mother's birth date (mm/dd/yyyy)

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

4th child's name:

FATHER

Father's first and last name

- -

Father's Social Security number

/ /

Father's birth date (mm/dd/yyyy)

() -

Father's phone

If you have more than 4 children who are age 18 or younger, add more pages with the same facts.

Father's mailing address	City	State	Zip
Father is: In home Out of home	Deceased	Employer
Father is: In home Out of home	Deceased	Employer




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

MOTHER	-	-	/	/
MOTHER	Mother's Social Security number		Mother's birth date (mm/dd/yyyy)
	Mother's Social Security number		Mother's birth date (mm/dd/yyyy)

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

	Application for benefits	H1010
		11/2019
	Texas Health and Human Services Commission
		Page 7

Section J

Other People in the Home

Other people in the home

These people live in my home, but they don't want to apply for benefits.

(Parents living with a child age 18 or younger who is applying or a spouse of a person applying should not be listed here — they should fill out a box in Section H.)

List the birth date only if the person is your relative.

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

Other facts

Answer 3, 4, and 5 only if anyone is applying for TANF cash help or SNAP food benefits.

Other facts

1. Does anyone have a disability?

Yes

If yes, who?

2. Is anyone getting cash help, food or health-care

Yes

benefits from another state?

If yes, who?

Which state?

When did that person last get benefits?

3. Has anyone been convicted of a felony for conduct that:

(1) took place after August 22, 1996, and (2) involved illegal drugs?

Yes

If yes, who?

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

• A homeless shelter.

• A drug treatment center.

Yes

• A shelter for battered women.

• A group home

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

or SNAP food benefits.

Is anyone living with you disqualified from getting cash help or food
benefits anywhere in the United States?	Yes	No
	Yes	No

Social Security number:

- -

Application for benefits

Texas Health and Human Services Commission H1010 11/2019

Page 8

Section L

Other health insurance

Medical

1. Does anyone get Medicaid, or CHIP?

Yes

Facts

If yes, from which state?

If yes, date coverage ends (if not ending, write “Not ending”):

This section

is only for

people

applying for

2. Does anyone get health coverage from one the following?

Yes

TANF, Medicaid

or CHIP.

Medicare

Employer Insurance

TRICARE (don’t check if you

Peace Corps

VA Health-care programs

have direct care or Line of Duty)

Other

If yes, give facts below.

Name of insured person (first, middle, last)

Insurance company

Policy number

Coverage start date

Coverage end date

Type of coverage

Amount you pay each month to cover

your children on this insurance.

Who pays the premium?

Is this COBRA coverage?

Yes

Is this a retiree health plan?

Yes

Is this a limited-benefit plan (like a school accident policy)?

Yes

Is this a state employee benefit plan?

Yes

Name of insured person (first, middle, last)

Insurance company

Policy number

Coverage start date

Coverage end date

Type of coverage

Amount you pay each month to cover

Who pays the premium?

your children on this insurance.

Is this COBRA coverage?

Yes

Is this a retiree health plan?

Yes

Is this a limited-benefit plan (like a school accident policy)?

Yes

Is this a state employee benefit plan?

Yes

Social Security number:

Application for benefits

H1010

Texas Health and Human Services Commission

11/2019

Page 9

Section L

Medical

Facts

(continued)

This section is only for people applying for TANF, Medicaid, or CHIP.

Medical bills from the past 3 months

If anyone on your case can't pay their medical bills, Medicaid might pay them.

•The bills must be for services they got in the past 3 months.

•You need to show proof of money you get (income) for the months they got services.

Does anyone applying for benefits have medical bills for services they got in the past 3
months?	Yes	No

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

Section M

Things Anyone is Paying for or Owns

Skip this section if you are applying only for Medicaid or CHIP.

If you need more room, add more pages with the same facts.

Vehicles

Does anyone own or is anyone paying for a:

• car • truck • boat • motorcycle

• other

Yes

If yes, give facts below.

Name of owner (first, middle, last)

Make / Model

Year

VEHICLE

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

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

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:

Application for benefits

Texas Health and Human Services Commission

H1010

11/2019

Page 10

Section M

Things Anyone is Paying for or Owns

(continued)

Skip this section if you are applying

only for Medicaid or CHIP.

If you need more room, add more pages.

Things anyone is paying for or owns

We need to know about items anyone owns or is paying for, such as:
• cash • bank accounts • homes and other property • insurance policies • stocks
Does anyone own or is anyone paying for these types of items?	Yes	No

If yes, give facts below.

				$
ITEM 1		Item	Account number	Value


	Names on account or deeds (include co-owners)
	Names on account or deeds (include co-owners)

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

			$
ITEM 2	Item	Account number	Value


	Names on account or deeds (include co-owners)
	Names on account or deeds (include co-owners)

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

				$
	Item	Account number	Value
ITEM 3

	Names on account or deeds (include co-owners)
	Names on account or deeds (include co-owners)

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

Section N

Money Coming into the Home

Money anyone might get from other programs

Is anyone waiting for an answer on an application for one of	Yes	No
the programs listed below?

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




Name of person waiting for an answer		Program name

Social Security number:

Application for benefits

H1010

Texas Health and Human Services Commission

11/2019

Page 11

Section N

Money Coming into the Home

(continued)

Money from jobs or training

Did anyone get money in the past 3 months from:

(a) working for someone else (b) training, or (c) working for themself?

Yes

If yes, give facts below.

before taxes and

deductions are taken

Name of person who got money

Hours worked

Amount paid

out

How often are you paid?

Start date

Last payment date (month/year)

daily

twice a month

once a week

once a month

every 2 weeks

other:

JOB

Is this person currently working at this job or in training?

Yes

Was this person working for themselves?

Yes

If no, list the person or place that paid the money.

before taxes and

deductions are taken

Name of person who got money

out

Hours worked

Amount paid

How often are you paid?

daily

twice a month

Start date

Last payment date (month/year)

once a week

once a month

JOB 2

every 2 weeks

other:

Is this person currently working at this job or in training?

Yes

Was this person working for themselves?

Yes

If no, list the person or place that paid the money.

before taxes and

deductions are taken

Hours worked

Amount paid

out

Name of person who got money

How often are you paid?

daily

twice a month

Start date

Last payment date (month/year)

once a week

once a month

every 2 weeks

other:

JOB

Is this person currently working at this job or in training?

Yes

Was this person working for themselves?

Yes

If no, list the person or place that paid the money.

Social Security number:

- -

Application for benefits

H1010

	Texas Health and Human Services Commission	11/2019
	Texas Health and Human Services Commission	Page 12
		Page 12

Section N

Money

Other money

Does anyone get, or expect to get, any of the types of money listed below?

Yes

If yes mark other types of money anyone gets or might get soon.

Coming into the Home

(continued)

Cash or gifts.

Supplemental Security Income (SSI)

Social Security

Retirement benefits

Veterans benefits

Child support anyone gets Pensions

Payments after being hurt at work (workers' compensation).

Payments after losing a job (unemployment compensation).

Alimony.

Interest or dividends.

Payments from private insurance

Loans paid to anyone on your case.

Payments to help with utilities. Farming or fishing

(after expenses paid)

Rent or royalty (after expenses paid)

Other

If anyone gets, or expects to get, any of these types of money, give the facts below.

MONEY TYPE 1

Type of money (item you marked above)	Amount you get paid

Name of person getting this money (if child support, list child's name)

Person, company, or agency paying the money

Last payment date (month/year)

How often are you paid?

daily

once a week

every 2 weeks

twice a month

once a month other:

MONEY TYPE 2

Type of money (item you marked above)	Amount you get paid

Name of person getting this money (if child support, list child's name)

Person, company, or agency paying the money

Last payment date (month/year)

How often are you paid?

daily

once a week

every 2 weeks

twice a month

once a month other:

MONEY TYPE 3

		$
Type of money (item you marked above)	Amount you get paid

Name of person getting this money (if child support, list child's name)

Person, company, or agency paying the money

Last payment date (month/year)

How often are you paid?

daily

once a week

every 2 weeks

twice a month

once a month other:

MONEY TYPE 4

Type of money (item you marked above)	Amount you get paid

Name of person getting this money (if child support, list child's name)

Person, company, or agency paying the money

Last payment date (month/year)

How often are you paid?

daily

once a week

every 2 weeks

twice a month

once a month other:

Social Security number:

H1010

Application for benefits

11/2019

Texas Health and Human Services Commission

Page 13

Section O

Housing

Costs

This section is only for people applying for SNAP benefits.

Housing costs

1. Does anyone pay any of the costs listed below for the home they are living in?

Yes

Or for a home they plan to return to?

If yes, mark the costs

Rent or home payment $

Natural gas/propane $

they have and list

Tax on home $

Phone $

the amount:

Water and sewer $

Home insurance $

Electricity $

Other $

2. If you pay rent, what is your landlord’s name and phone number?

Landlord's name	Phone


3. Does another person not living in the home help anyone on your		Yes	No
case pay for housing costs?		Yes	No

Section P

Costs to Take Care of Others

Costs to take care of others

Does anyone have costs
to take care of others?	Yes	No

If yes, give facts below.

Examples:

•Child care costs so someone can work, look for work, go to training, or go to school.

•Costs for people with disabilities or adults who need help caring for themselves.

•Child support payments, medical bills, and health insurance you pay for a child living outside the home.

•Alimony payments.

COST 1

Type of costFirst name of person who gets care or support

		$		/	/

	Amount paid
Who pays the cost?	Amount paid		Date last paid

How often you paid?

daily

once a week

every 2 weeks

twice a month

once a month other:

				For court ordered child support
				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)

COST 2

Type of costFirst name of person who gets care or support

	$		/	/

Who pays the cost?	Amount paid	Date last paid

How often you paid?

daily

once a week

every 2 weeks

twice a month

once a month other:

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

COST 3

Type of costFirst name of person who gets care or support

		$		/	/

Who pays the cost?	Amount paid		Date last paid

How often you paid?

daily

once a week

every 2 weeks

twice a month

once a month other:

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

Social Security number:

Application for benefits

Texas Health and Human Services Commission

H1010

11/2019

Page 14

Section Q

Medical costs

This section is only for people applying for Medicaid, CHIP, or SNAP food benefits.

Section R

People

Helping

You

Medical costs

Does anyone age 60 or older, or anyone with a disability,
pay medical costs?			Yes	No
If yes, mark the type of costs they pay:
Doctor	Hospital	Medicine	Health insurance

People helping you

Did someone help you fill out this form?

Yes

If yes, tell us about that person:

	Name

		( ) -
Relationship or organization		Phone

Address

Preferred Method of Contact by Health Plan Providers or Managed Organizations

For pregnant individuals only

If you get health benefits from us, your health plan provider or managed care organization may contact you for things like appointment reminders and information about immunizations or well-check visits.

You can choose to have them contact you by telephone, text message, or email. Please rank how you would prefer to be contacted, with 1 being your most preferred.

Name

Language you prefer to be contacted in:

By Telephone

By Text message

By e-mail

Telephone number:

(If contacted by cellular telephone, the call may be autodialed or prerecorded, and your carrier’s usage rates my apply.)

Cellular telephone number:

(Carrier message and data rates may apply.)

E-mail address:

Social Security number:

	Application for benefits	H1010
		11/2019
	Texas Health and Human Services Commission
		Page 15

Section S

Signing Up to Vote

(optional)

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, PO Box 12060, Austin, TX 78711. Phone: 1-800-252-8683

Agency Use Only: Voter Registration Status

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


			Agency staff signature
			Agency staff signature

Section T

APerson Who Can Act for You

Don't forget to sign page 19.

Person who has the right to act for you

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

•Give and get facts for this application.

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

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

•Take any action needed for you to get benefits. This includes reporting changes and renewing benefits. If you give someone the right to act for you, that person agrees to:

•fulfill all your responsibilities related to Medicaid;

•keep information about you private;

•obey state and federal laws about conflict of interest and keeping information private, including:

•laws that protect information on people who apply for or receive Medicaid (42 CFR part 431, subpart F);

•laws about the privacy and safety of personally identifiable information (45 CFR §155.260(f)); and

•laws barring the state from paying anyone other than your provider or you for Medicaid services, except in a few circumstances (42 CFR §447.10).

Do you want to give someone the right to act for you -- to be your	Yes	No
authorized representative?

If yes, tell us about that person (the authorized representative) by filling out Appendix C. It is attached to this form.

Social Security number:

	Application for benefits	H1010
		11/2019
	Texas Health and Human Services Commission
		Page 16

Section U

Legal information

Legal Information

Your Right to be Treated Fairly

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

Supplemental Nutrition Assistance Program (SNAP)

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW Washington, D.C. 20250-9410

(2)fax: (202) 690-7442; or

(3)email: program.intake@usda.gov

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the

USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

Medicaid and Temporary Assistance for Needy Families

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

You also can file a complaint with the Texas Health and Human Services Commission, Civil Rights Office. Email HHSCivilRightsOffice@hhsc.state.tx.us, call

1-888-388-6332, fax (512) 438-5885, or write Texas Health and Human Services Commission, Civil Rights Office, 701 W. 51st St., MC W206, Austin, Texas 78751.

Citizenship and Immigration Status

You can get benefits for your children who are U.S. citizens or legal immigrants even if you are not a U.S. citizen or a legal immigrant. You do not have to give your citizenship or immigration status to get benefits for your children. You only have to give the citizenship or immigration status of people who want benefits. If you are not a U.S. citizen or a legal immigrant, the only benefits you might be able to get are emergency Medicaid services. Getting long-term care (Medicaid for the Elderly and People with Disabilities) or cash help (TANF) could affect your immigration status and your chances of getting a Permanent Resident Card (green card). Getting other benefits will not affect your immigration status and your chances of getting a Permanent Resident Card. You might want to talk to an agency that helps immigrants with legal questions before you apply. If you are a refugee or have been given asylum, getting benefits will not affect your chances of getting a Permanent Resident Card or becoming a citizen.

Social Security Numbers

You only need to give the Social Security numbers (SSNs) for people who want benefits. Giving or applying for an SSN is voluntary; however, anyone who doesn’t apply for an SSN or doesn’t give an SSN can’t get benefits. If you don’t have an SSN, we can help you apply for one if you are a U.S. citizen or a legal immigrant. You must be a U.S. citizen or a legal immigrant to get an SSN. You can get benefits for your children if they have an SSN and you don’t. We will not give SSNs to the Bureau of Immigration and Customs Enforcement. We will use SSNs to check the amount of money you get (income), if you can get benefits, and the amount of benefits you can get. (7 C.F.R 273.6 for food benefits; 45 C.F.R 205.52 for TANF; and 42 C.F.R 435.910 for health care.)

Social Security number:

Application for benefits

H1010

Texas Health and Human Services Commission

11/2019

Page 17

Section V	All Benefit Programs			SNAP Food Benefits
	Facts HHSC Has About Me			SNAP Food Benefits
	Facts HHSC Has About Me			Telling the Truth
Statement of	HHSC uses facts about people applying for benefits to			Telling the Truth
Statement of	HHSC uses facts about people applying for benefits to			Anyone who applies for or gets SNAP must:
	decide: (1) who can get benefits, and (2) the amount			Anyone who applies for or gets SNAP must:
Understanding	decide: (1) who can get benefits, and (2) the amount			• Tell the truth.
Understanding	of benefits. HHSC checks facts with the federal

	Income and Eligibility Verification System. If any			• Never trade or sell SNAP benefits, Lone
Read Section W	Income and Eligibility Verification System. If any			Star Cards, or other devices that allow people
	facts don't match, HHSC will check other sources			Star Cards, or other devices that allow people
	facts don't match, HHSC will check other sources			to get SNAP.
before signing	(banks, employers, etc.). If anyone applying for			to get SNAP.
before signing	(banks, employers, etc.). If anyone applying for			• Never use or have Lone Star Cards or other
page 19.	benefits has an immigration registration number,			devices if they don't belong to them.
	HHSC must check with the U.S. Citizenship and
	Immigration Services' (USCIS) system. HHSC			Anyone who chooses
	will not give anyone's facts to USCIS.			Anyone who chooses
	will not give anyone's facts to USCIS.			not to tell the truth might:
				not to tell the truth might:
	In most cases, I can see and get facts HHSC has about			• Not get SNAP for a year or more.
	In most cases, I can see and get facts HHSC has about			• Not get SNAP for a year or more.
	me. This includes facts I give HHSC and facts HHSC			• Be fined up to $250,000, jailed up to
	gets from other sources (medical records, employment			20 years, or both.
	records, etc.). I might have to pay to get a copy of these			• Lose income tax refunds.
	facts. I can ask HHSC to fix anything that is wrong. I do			• Be charged with other crimes.
	not have to pay to fix a mistake. To ask for a copy or to			• Have to repay benefits.
	fix a mistake, I can call 2-1-1 or my local HHSC benefits			• Never get SNAP again.
	office.
				The same is true if anyone lets someone else use
	Keeping My Facts Private			their Lone Star Card.
	HHSC will keep my facts private if they were collected:			Facts Anyone Tells or Gives HHSC
		• By HHSC staff or contracted provider staff.		Facts Anyone Tells or Gives HHSC
		• To find out if I can get state benefits.		HHSC uses the facts anyone tells or gives HHSC,
				including Social Security numbers to:
	HHSC can share facts about me:
		• When needed for me to get state health-care benefits.		• Check if that person can get benefits.
		• With phone and utility companies. They will find out if		• Check that person's facts with computer
			my bill amount can be lowered. HHSC will give them	matching programs and credit reporting
			my name, address, and phone number.	agencies.
				• Make sure that person is following benefit
			TANF Cash Help for Families	program rules.
			TANF Cash Help for Families	• Help other agencies check if that person can
				• Help other agencies check if that person can
			Child Support or Alimony	get other benefits.
			Child Support or Alimony	• Recover benefits that person wasn't
			I agree to:	supposed to get.
			• Let the state keep any child support or alimony	• Share facts about that person: (1) with
			money owed to anyone during the time they	other state and federal agencies (for example,
			get TANF.	the Texas Workforce Commission, the Social
			• Let the state keep this money after TANF benefits	Security Administration, and the Internal Revenue
			end, if the TANF amount anyone got still needs to	Service); (2) with law enforcement officials so they
			be paid off.	can find people on that person's benefits case (the
			• Tell HHSC about money anyone gets.	household) who are wanted for fleeing the law;
			• Tell HHSC about money anyone gets.	household) who are wanted for fleeing the law;
			• Work with HHSC to get this money; if I don't, I am	and (3) with federal, state, and private claims
			breaking the law.	collecting agencies for food benefit overpayment
				claims collection action.
			The state will keep only the amount allowed by law.
			If I Give False Information	(Food and Nutrition Act of 2008,
			If I choose not to tell the truth, I might:	as amended, 7 U.S.C. 2011-2036.)
			If I choose not to tell the truth, I might:
			• Be charged with and punished for a crime.
			(This could include going to prison for up to 10
			years or community supervision.)	More on next page
			• Have to repay benefits.	More on next page
			• Never get TANF again.

Social Security number:

Application for benefits

Texas Health and Human Services Commission

H1010

11/2019

Page 18

Section W

Statement of Understanding

Did you...

1.Sign and date page 1 (if you have not already sent it in).

2.Include the "items we need" listed in the cover section.

3.Sign and date this page.

Medicaid

If I Give False Information

If I choose not to tell the truth, I might:

•Be charged with a crime.

•Have to repay benefits.

The same is true if I let someone else use my medical card or Medicaid ID.

Giving Out Facts About Me

I agree to let Medicaid health care providers (doctors, drug stores, hospitals, etc.) give out any facts about me to HHSC. This will allow the providers to be paid by Medicaid.

Medical and Child Support Payments

Depending on my benefits case, the Attorney General (the state) might check that I am getting the right amount of child or medical support payments

and coverage.

•If only my child gets Medicaid, I can decide if I want the state to help get any payments and coverage we should get, but don't get right now.

•If my child and I both get Medicaid, I must:

-Help the state get any payments and coverage we should get, but don't right now.

If I don't help the state, my child can get Medicaid, but I might not.

-Identify who the child's other parent is.

-Allow the state to keep any medical support payments.

•I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell HHSC and I may not have to cooperate.

If I get Medicaid, HHSC will keep medical service payments I can get from other sources, such as:

•My health insurance.

•Money I got because of injuries.

•Money collected for me or my children by the Office of Attorney General.

I must tell HHSC about these sources. If I don't, I am breaking the law.

HHSC will only keep the amount of medical support and service payments allowed by law. I will work with HHSC to get these funds.

By signing below, I agree:

•To let HHSC and other state, federal, and local agencies check, share, and get facts about anyone on my benefits case (the household).

•To let other people, businesses, and organizations share facts they have about anyone on my benefits case (the household) with HHSC.

•The facts to be checked and shared include anything that helps decide: (1) who can get benefits, and (2) the amount of benefits.

My Answers Are True

Sign here to show your agree:

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.

Person applying on their authorized representative

Sign here	Date (mm/dd/yyyy)

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

(

)

Sign here (you must give proof of this right)

Phone

Date (mm/dd/yyyy)

Witness (only needed if anyone above signed with an "X" or other mark).

Sign here	Date (mm/dd/yyyy)
Sign here

Printed name of witness

Ready to send this form to us? See “How to send it” at the bottom of page A.

Social Security number:

- -

	Application for benefits	H1010
	Texas Health and Human Services Commission	H1010
	Texas Health and Human Services Commission	11/2019

Page 19

Applying for or renewing

Medicaid or CHIP? If yes, you must fill out this form.

NEED HELP WITH YOUR APPLICATION?

We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905 (after you pick a language, press 2). If you have a hearing or speech disability, call 7-1-1 or any relay service.

Section 1

Your Tax

Return

This form needs to be filled out, signed, and sent back with your application for benefits.

Are you afraid that giving us facts about someone could cause harm (physical or emotional) to you or your child?

If yes, you might not have to give us facts about that person. You might be able to get the “Family Violence Exemption.”

Each person listed in Section H of the Your Texas Benefits application needs to answer the questions below (Section 1). The people who should be included in Section H and who should answer the questions below are:

• Yourself.	• Anyone you include on your tax
	return, even if they don’t live with you.
• Your spouse.
	• Anyone else age 20 and younger who
• Your children age 20 and younger	you take care of and lives with you.
who live with you.

(You can still apply for health insurance even if you don’t file a federal income tax return.)

Person 1: (main contact or head of household)


First name		Middle name	Last name
If married, name of spouse:



	Do you plan to file a federal income tax return next year?			Yes	No
	If yes, answer questions a to c. If no, skip to question c.
	If yes, answer questions a to c. If no, skip to question c.
	...................................................a. Will you file jointly with a spouse?			Yes	No
	b. Will you claim any dependents on your tax return?			Yes	No

If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?			Yes	No
	If yes, list the name of tax filer:	How are you related to the tax filer?

Application for benefits
Texas Health and Human Services Commission	More on page 2-A
	More on page 2-A
Addendum A . H1010-M
11/2019
Page 1-A

Section 1

Your Tax Return

(continued)

Person 2:

First name

Middle name

Last name

If married, name of spouse:

Do you plan to file a federal income tax return next year?

Yes

If yes, answer questions a to c. If no, skip to question c.

...................................................a. Will you file jointly with a spouse?

Yes

b. Will you claim any dependents on your tax return?

Yes

If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?

Yes

If yes, list the name of tax filer:

How are you related to the tax filer?

Does Person 2 live at the same address as Person 1?

Yes

If no, what is Person 2's address?

Person 3:

First name

Middle name

Last name

If married, name of spouse:

Do you plan to file a federal income tax return next year?

Yes

If yes, answer questions a to c. If no, skip to question c.

...................................................a. Will you file jointly with a spouse?

Yes

b. Will you claim any dependents on your tax return?

Yes

If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?

Yes

If yes, list the name of tax filer:

How are you related to the tax filer?

Does Person 3 live at the same address as Person 1?

Yes

If no, what is Person 3's address?

Addendum A . H1010-M 11/2019

Page 2-A

Section 1

Your Tax Return

(continued)

Person 4:

First name

Middle name

Last name

If married, name of spouse:

Do you plan to file a federal income tax return next year?

Yes

If yes, answer questions a to c. If no, skip to question c.

...................................................a. Will you file jointly with a spouse?

Yes

b. Will you claim any dependents on your tax return?

Yes

If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?

Yes

If yes, list the name of tax filer:

How are you related to the tax filer?

Does Person 4 live at the same address as Person 1?

Yes

If no, what is Person 4's address?

If more than

5 people are applying for benefits, add more pages with the same facts.

Addendum A . H1010-M 11/2019

Page 3-A

Person 5:

First name

Middle name

Last name

If married, name of spouse:

Do you plan to file a federal income tax return next year?

Yes

If yes, answer questions a to c. If no, skip to question c.

a. Will you file jointly with a spouse?

Yes

b. Will you claim any dependents on your tax return?

Yes

If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?

Yes

If yes, list the name of tax filer:

How are you related to the tax filer?

Does Person 5 live at the same address as Person 1?

Yes

If no, what is Person 5's address?

Section 2

Tax deductions you claim

Tell us about things that can

be deducted on a federal income tax return. If anyone has deductions, health coverage costs might

be a little lower.

Tax deductions

Mark all that apply, give the amount, and how often you pay it.

(You shouldn’t include a cost that you already considered as part of your net self-employment.)

Alimony paid $	How often?
Student loan interest $	How often?

Other deductions, such as educator expenses, health savings accounts, moving

expenses, tuition and fees $

How often?

Types

If you have any of these deductions, you will need to send us a copy of your last year’s income tax return.

Section 3

Information about people applying for benefits

1. Does a child applying for health care travel with a family member
who is a migrant farm worker?	Yes	No

If yes, what is the name of that child or children?

2.	Is a child in the Children with Special Health Care Needs program?			Yes	No
				Yes	No
	If yes, who?


3. Is anyone an American Indian or Native Alaskan?				Yes	No
		If yes, you must fill out “Appendix B: American Indian


		or Alaska Native Family Member.” It is attached to this form.
4.	Was anyone in foster care when they were age 18 or older?			Yes	No
				Yes	No
		If yes, who?	In which state?

5. Does any child on this application have a parent living
outside of the home?	Yes	No

Addendum A . H1010-M 11/2019

Page 4-A

Section 4

Money you get

Fill out this section only if the amount of money you get changes or might change from month to month. If you don’t expect changes to your monthly income, skip this question.

Your total income this year:	Your total income next year (if you think it will be different):

$		$

Section 5

Insurance offered through your job

1. Can anyone listed on this form get health insurance through a job? (Check yes even if the

coverage is from someone else's job, such as a parent or spouse.)	Yes	No

If yes, you must fill out “Appendix A: Health coverage from job."

2. Did anyone have insurance through a job and lose it
	within the past 3 months?			Yes	No
				Yes	No
	If yes, who?		If yes, end date:


	If yes, reason the insurance ended:
	Parent’s job ended due to	CHIP benefits from another		Death of a parent.
	layoff or business closing.	state ended.		The child has special
				The child has special
	Parent’s COBRA or ERS	Medicaid benefits from		health-care needs.
	coverage ended.	another state ended.		Medicaid benefits ended
				Medicaid benefits ended
	Change in parent’s	Private health coverage		(for any reason).
	Change in parent’s	Private health coverage
	marital status.	ended.		Others

Section 6

Read and sign this form

Addendum A . H1010-M 11/2019

Page 5-A

A. Is anyone who is applying for health coverage
in jail (incarcerated)?	Yes	No

If yes, who is in jail?

B. Renewing your health coverage in future years

To make it easier to find out if I can get help paying for health coverage in future years, I agree to allow the agency to use facts about money I get (income data), including information from tax returns. The agency will send me a notice, let me make any changes, and I can cancel (opt out) at any time.

I agree: Yes, the agency can get facts listed above and renew my health coverage without asking me for the next:

5 years (the maximum	3 years	Don’t use information from
number of years allowed)	2 years	tax returns to renew
		tax returns to renew
		my coverage.
4 years	1 years	my coverage.
	1 years

					/			/
Sign here		Date (mm/dd/yyyy)

APPENDIX A

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to include this page when you send in your application, not the Employer Coverage Tool.

EMPLOYEE Information

1. Employee name (First, Middle, Last)

2. Employee Social Security number

EMPLOYER Information

3.Employer name

5.Employer address

4.Employer Identification Number (EIN)

6.Employer phone number

( ) -

7. City

8. State

9. ZIP code

10.	Who can we contact about employee health coverage at this job?

11.	Phone number (if different from above)		12. Email address
(	)	-

13.Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue)

13a. If you’re in a waiting or probationary period, when can you enroll in coverage?

List the names of anyone else who is eligible for coverage from this job.			(mm/dd/yyyy)

Name:	Name:	Name:

No (Stop here and go to page 9, Section L)

Tell us about the health plan offered by this employer.

14. Does the employer offer a health plan that meets the minimum value standard*?		Yes		No

15.For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):

If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

16.What change will the employer make for the new plan year (if known)?

Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much would the employee have to pay in premiums for this plan? $

b. How often?	Weekly	Every 2 weeks	Twice a month	Once a month	Quarterly	Yearly
Date of change (mm/dd/yyyy):

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

Appendix A . H1010-M 11/2019

Page 6-A

EMPLOYER COVERAGE TOOL

Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even if it’s

from another person’s job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.

Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage.

EMPLOYEE Information

The employee needs to fill out this section.

1. Employee name (First, Middle, Last)

2. Social Security number

EMPLOYER Information

Ask the employer for this information.

3.Employer name

5.Employer address

4.Employer Identification Number (EIN)

6.Employer phone number

( ) -

7. City

8. State

9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above)

( ) -

12. Email address

13.Is the employee currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue)

	13a. If the employee is not eligible today, including as a result of a waiting
	or probationary period, when is the employee eligible for coverage?		(mm/dd/yyyy)

	No (Stop and return this form to employee)		(Continue)

Tell us about the health plan offered by this employer.

Does the employer offer a health plan that covers an employee’s spouse or dependent?

Yes Which people?

Spouse

Dependent(s)

(Go to question 14)

14. Does the employer offer a health plan that meets the minimum value standard*?

		Yes (Go to question 15)		No (STOP and return form to employee)

15.For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):

a.How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16.What change will the employer make for the new plan year?

Employer won’t offer health coverage

a. How much would the employee have to pay in premiums for this plan? $

b. How often?	Weekly	Every 2 weeks	Twice a month	Once a month	Quarterly	Yearly
Date of change (mm/dd/yyyy):

Appendix A . H1010-M 11/2019

Page 7-A

Appendix B

American Indian or Alaska Native Family Member (AI/AN)

Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your application.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach.

		AI/AN PERSON 1			AI/AN PERSON 2

1. Name	First		Middle	First		Middle
(First name, Middle name, Last name)

	Last			Last

2. Member of a federally recognized tribe?	Yes			Yes
	Yes			Yes
		If yes, tribe name			If yes, tribe name

		No			No

3. Has this person ever gotten a service from		Yes			Yes
the Indian Health Service, a tribal health		Yes			Yes
the Indian Health Service, a tribal health
program, or urban Indian health program,		No			No
or through a referral from one of these		If no, is this person eligible to get			If no, is this person eligible to get
programs?		If no, is this person eligible to get			If no, is this person eligible to get
programs?		services from the Indian Health Service,			services from the Indian Health Service,
		services from the Indian Health Service,			services from the Indian Health Service,
		tribal health programs, or urban Indian			tribal health programs, or urban Indian
		health programs, or through a referral			health programs, or through a referral
		from one of these programs?			from one of these programs?
		Yes	No		Yes	No

4.Certain money received may not be counted for Medicaid or the Children’s Health

Insurance Program (CHIP). List any income	$	$
(amount and how often) reported on your
application that includes money from	How often?		How often?
these sources:	How often?		How often?
these sources:
• Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties
• Payments from natural resources,
farming, ranching, fishing, leases,
or royalties from land designated as
Indian trust land by the Department
of Interior (including reservations and
former reservations)
• Money from selling things that have
cultural significance

Appendix B . H1010-M 11/2019

Page 8-A

APPENDIX C

Assistance with Completing this Application

You can choose an authorized representative.

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

•Give and get facts for this application.

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

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

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

If you give someone the right to act for you, that person agrees to:

•fulfill all your responsibilities related to Medicaid;

•keep information about you private;

•obey state and federal laws about conflict of interest and keeping information private, including:

•laws that protect information on people who apply for or receive Medicaid (42 CFR part 431, subpart F);

•laws about the privacy and safety of personally identifiable information (45 CFR §155.260(f));

•laws barring the state from paying anyone other than your provider or you for Medicaid services, except in a few circumstances (42 CFR §447.10).

You can have only one authorized representative for all your benefits from HHSC. If you want to change your authorized representative: (1) log in to your account on YourTexasBenefits.com and report a change, or (2) call 2-1-1 (after you pick a language, press 2). If you’re a legally appointed representative for someone on this application, send proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

2.Address

4.City

7.Phone number

( ) -

8.Organization name

	3. Apartment or suite number
5. State	6. ZIP code

9. Organization ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency.

10. Your signature

11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else.

1.Application start date (mm/dd/yyyy)

2.First name, middle name, last name, & suffix

3. Organization name

4. Organization ID number (if applicable)

Appendix C . H1010-M 11/2019

Page 9-A

How to Edit Form H1010 Online for Free

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In an effort to fill out this form, make certain you type in the information you need in every blank field:

1. To start off, while completing the benefits applying how download, beging with the page that has the subsequent blank fields:

application benefits how form completion process clarified (stage 1)

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Writing section 3 of application benefits how form

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If yes give your facts below, Social Security number, and Are you applying for benefits for of application benefits how form

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4. Will you need an interpreter? We can get one for you for free

If yes, mark the one you need:

Vietnamese

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American Sign Language

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