Form H1801 Snap PDF Details

The Texas Health and Human Services Commission plays a crucial role in assisting families in need through various programs, one notable being the Supplemental Nutrition Assistance Program (SNAP), facilitated through the H1801 SNAP Worksheet Form. Implemented since February 2010, this form serves as a detailed worksheet to aid in the accurate evaluation of a household's eligibility for SNAP benefits. It encompasses a comprehensive scrutiny starting from the verification of the applicant's identity, income assessment, to the determination of net income, ensuring all criteria for assistance are meticulously evaluated. The form delves into specific household situations, including citizenship status, resource determination, employment services, and even arrangements for finger imaging to bolster program integrity. It mandates the provision of essential documentation such as proof of earnings or income and calculates both gross and net income to determine eligibility. With sections devoted to adjustments, management problems, and special reviews, the H1801 form is designed to streamline the eligibility assessment process, thereby facilitating a more efficient allocation of SNAP benefits to qualified applicants. Through this systematic approach, Texas aims not only to meet the immediate nutritional needs of its residents but also to uphold the integrity and effectiveness of the SNAP program.

QuestionAnswer
Form NameForm H1801 Snap
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesform h1808 snap, form h1808 snap work rules, form 1808 snap rules, form 1808

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Texas Health and Human Services Commission

SNAP Worksheet

Form H1801

February 2010

Case Name (Last, First, Middle)

 

App./Case No.

 

ID

 

 

Input Seq. No.

 

 

 

 

 

 

 

 

 

Person Interviewed

 

 

Form H1010-B Signed and Dated?

 

 

Date Received

 

 

 

 

YES (Do not proceed further until signed and dated.)

 

 

Interview Type

 

Date

Name of Authorized Representative

Are all household members U.S. citizens

Office

Home

Telephone

 

 

 

 

or eligible aliens?

Yes

No

Is anyone applying or receiving

If yes, who?

 

Where?

 

When?

 

 

TANF?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has residence been verified?.....

Yes

No If yes, how? (Also document out-of-county applications)

STEP 1 – Resource Determination

TYPE

VALUE

TYPE

VALUE

TYPE

VALUE

Countable Value of Resources $

Is household eligible based on resources?

Yes

No

 

 

 

 

 

Brief Description of Household Situation:

List disqualified members and reason:

Document if a disqualified member has regained eligibility:

STEP 2 – Gross Income Determination

1.Gross Earned Income (include net earned self-

employment–attach Form H1049 or other

BUDGET

BUDGET

documents.)

No. 1

No. 2

NAME

Amount

Amount

a.

b.

c.

d.

e. Total gross earned income (add lines a thru d)

2.Unearned Income

a.Worker's Compensation

b.TANF Grants

c.Other (include net unearned self-employment)

d.Subtotal (a thru d) (Form H1000-A/B, Item 56)

e.RSDI/RR

f.VA/unemployment compensation/pension

g.SSI

h.Total (add d, e, f, g)

3.Total Gross Income Subtotal (add 1.e. and 2.h.)

4.

Is household subject to gross income test?

Yes

No

5.

Is household eligible based on total gross income?

Yes

No

VERIFICATION DOCUMENTATION

FOR INCOME

1. Date of Check

3. Source

5. Frequency

INCLUDE

 

 

 

 

2. Date Received

4. Gross Pay

6. Calculations

NA

Form H1801, Page 2/02-2010

 

BUDGET

BUDGET

STEP 3 – Net Income Determination

No. 1

No. 2

1.Total Gross Inc. (from STEP 2, Item 3)

2.Earned Inc. Ded. (20% of STEP 2, 1.e.)

3.Remaining Farm Loss (if NA, enter 0)

4.Standard Deduction

5.Allowable Medical Costs (Actual or Standard)

6.Homeless Shelter Standard

7.Monthly Dependent Care Costs

8. Child Support Paid to/for Non-Household Members

9.Total Deductions (add 2,3,4,5,6,7 and 8)

10.Adjusted Gross Income (Item 1 minus 9)

11.Shelter Expenses:

a.Housing

b.Utility or Telephone Standard

c.Expedited Only -

Actual Utilities (1) Gas

(2)Electric

(3)Water/Sewage

(4)Other (explain):

d. Total Shelter Costs

e.Subtract 50% Adjusted Gross Income

f.Total Excess Shelter Costs

12.

Maximum Excess Shelter (if applicable)

 

 

 

 

13.

Net Income (Item 10 minus 11.f. or 12)

 

 

 

 

14.

Rounded Net Income

 

 

 

 

15.

Is household eligible based on net income?

Yes

No

NA

16.Number of Certified Members ............................... ….

17.Monthly Allotment (TW Handbook C-1431)

18.Prorated Allotment (if applicable)

TW Handbook C-1432)…………………………………

19.

Months Covered by First Budget………..

 

thru

20.

Months Covered by Second Budget……

 

thru

STEP 4 – Management: Document any management problems and explain.

STEP 5 – Employment Services: List household members and their exemption or registration/education codes:

Form H1801, Page 3/02-2010

MEMBER

CODE

MEMBER

CODE

MEMBER

CODE

MEMBER

CODE

Justify codes for household members coded E or H:

Does the household qualify to select the PWE?

Yes

No

If yes, do all adult household members agree on the selection?

Yes

No

If yes, give the name of the PWE:

STEP 6 – Finger Imaging: List household members who require imaging and their exemption code or enrollment code and VUN:

MEMBER

CODE

VUN

MEMBER

CODE

VUN

Justify all exemption codes and enrollment code Z:

STEP 7 – Basis of Certification or Denial

Certified

From:To:

Special Review Date

Reason Code

1.Special Review and Certification Period Explanation:

2.Denial Explanations:

STEP 8 – SNAP Forms and Referrals

1.Form H1009, H1017, H1019 provided? ........................................................................................................................................................................

2.Right to appeal explained? ............................................................................................................................................................................................

3.Form H1805 provided and all reminders explained? ....................................................................................................................................................

4.Form H1808 provided for each employment services registrant?.................................................................................................................................

5.Form H2067 sent to associated TANF cases? .............................................................................................................................................................

6.Has Form H1106 been returned by SSA?.....................................................................................................................................................................

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

IF YES, FOR WHOM

DATE

DOCUMENT PROBLEMS/DISQUALIFICATION

7.

 

Form H1823 completed for members age 18 - 50?

 

 

 

NA

Yes

No

8.

 

Referrals to:

 

……….

PA SNAP

Social Services

9.

a.

EBT card, PIN, and training material provided (Form H1172/H1175 sent)?

 

 

 

NA

Yes

No

 

b.

Form H1803 provided if appropriate?

NA

Original

Duplicate

No

ID No.:

 

 

Documentation/Changes:

Signature – Worker

Date

Form H1801, Page 4/02-2010

Case Name (Last, First, Middle)

Case No.

Input Seq. No.

Document Changes: Include change, date of change and date reported:

 

BUDGET

BUDGET

ADJUSTMENTS

No. 1

No. 2

1.Gross Earned Income

2.Gross Unearned Income

3.

Total Gross Income Subtotal (add Items 1 and 2)

 

 

 

 

Is household eligible based on gross income?

Yes

No

NA

4.Earned Income Deduction (20% of Item 1)

5.Remaining Farm Loss (if NA, enter 0)

6.Standard Deduction

7.Allowable Medical Costs (Actual or Standard)

8.Homeless Shelter Standard

9.Dependent Care Expense

10.Child Support Paid to/for Non-Household Member

11.Total Deductions (add Items 4 thru 10)

12.Adjusted Gross Income (Item 3 minus 11)

13.Total Shelter Cost

 

a. Subtract 50% of Item 12

 

 

 

 

 

 

b. Total Excess Shelter Costs

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Maximum Excess Shelter (if applicable)

 

 

 

 

 

15.

Net Income (Item 12 minus Item 13b or 14)

 

 

 

 

 

16.

Rounded Net Income

 

 

 

 

 

 

 

 

 

 

 

 

 

Is household eligible based on net income?

Yes

No

NA

Denied, effective

 

 

 

 

 

...................................................Effective date of change

 

 

 

 

 

Employment services registration changed?

 

Yes

No

Special review (mm/yy)

 

 

 

 

 

...................................................................Reason Code

 

 

 

 

 

Household Size:

 

Allotment: $

 

 

 

 

 

 

 

 

 

 

 

 

Form H1823 updated for members age 18 - 50?

Yes

No

NA

Form H2067 sent to associated TANF cases

 

Yes

No

 

Form H1019

Form H1172/H1175

Form

 

 

 

VERIFICATION DOCUMENTATION

FOR INCOME

1. Date of Check

3. Source

5. Frequency

INCLUDE

2. Date Received

4. Gross Pay

6. Calculations

 

 

 

 

Signature – Worker

Date