Form H1840
December 2014-E
SNAP food benefits renewal form
Fill out this form. Then mail it using the pre-paid envelope. If you need help filling out this form or have questions, call toll-free 2-1-1 or 1-877-541-7905 (after you pick a language, press 2).
Main contact (head of household)
Name (first, middle, last)
Home address — street and apartment number
Mailing address (if different from home address)
Phone number (do not leave blank)
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Home |
Someone else's phone where a message can be left |
If we need to talk to you on the phone, will you need an interpreter? We can get an interpreter at no cost to you.
Yes |
No |
If yes, what language? |
People applying for benefits, living in your home, helping with your case
1.Tell us about everyone who is applying for benefits. (If you need more room, add another page.)
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How is this |
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Name (first, middle, last) |
person related |
Date of birth |
Sex |
Race |
to the main |
(optional) |
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contact? |
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Main contact |
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Self |
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U.S. |
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Legal |
In school? |
citizen? |
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immigrant? |
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Yes |
No |
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No |
Yes |
No |
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2.Tell us about people who aren't applying for benefits, but who live in your home. (If you need more room, add another page.)
Name (first, middle, last)
How is this person related to the main contact?
3. Does anyone listed in Question 2 buy and cook their food separately from the people listed in Question 1? ...............
(Answer yes if they don't now, but plan to in the near future.)
4.Along with the main contact or their spouse, someone else can be given the right to act for people on this SNAP benefits case. A person helping with this case is known as an "authorized representative." This person can help everyone on this case: (1) give and get facts about this case, (2) take any action needed, including appealing a Texas Health and Human Services Commission (HHSC) decision, and (3) take any action needed for people on this case to get SNAP benefits, including reporting changes. If someone needs to be given the right to help on this case (to be the authorized representative), tell us about that person here. Also, at the end of this form, that person will need to sign their name where it says "Person helping with this case (authorized representative) signature."
Address (street, city, state, ZIP)
FOR AGENCY USE ONLY
Status |
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App/Case No. |
Received in Wrong Office |
Mail Code |
Date Received |
Data Broker |
Screened By: |
App |
Recert |
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Y |
N |
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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 cash help (TANF) or food benefits (SNAP). Is anyone
living in this home disqualified from getting cash help or food benefits anywhere in the United States?.......................
If yes, who?
Form H1840
Page 2 / 12-2014-E
6. Has anyone been convicted of a felony that: (1) took place after Aug. 22, 1996, and (2) involved illegal
drugs?............................................................................................................................................................................
If yes, who?
7.Has anyone: (1) been charged with or convicted of a felony and is fleeing the police, or (2) broken a rule of their probation or parole? ......................................................................................................................................................
If yes, who?
Money coming into the home
8. Did anyone in your home get money from job training or work?...................................................................................
If yes, tell us about each person who got this type of money:
Person working or in training |
Address of employer or training place |
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Phone number of employer or training place
How often paid?
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week |
weeks |
a month |
Daily |
Once a |
Every 2 |
2 times |
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month |
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Amount paid |
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(before taxes and |
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deductions are |
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taken out) |
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9.Tell us about the type of money everyone in the home gets:
Type of money |
Person who gets the money |
Amount |
How often paid? |
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SSI (Supplemental Security Income)
Social Security
Veteran's pension/compensation
Railroad Retirement
Other pensions
Interest, rental income, dividends, royalties, child support
10.Does anyone in the home get cash, gifts, loans or money from parents, relatives, friends or others (include cash from baby-sitting or selling cans)? .................................................................................................................................
If yes, tell us: (1) type of money, (2) amount, (3) how often paid, (4) person who gets the money, and (5) person who pays the money:
11.Does anyone in the home put money or other things they own into a Plan for Achieving Self-Support (PASS) account approved by the Social Security Administration? ...........................................................................
If yes, send proof.
Form H1840
Page 3 / 12-2014-E
Costs you pay
12.Tell us about the bills everyone pays:
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Total |
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Amount you pay |
How often billed? |
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Costs |
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Medical costs: Does anyone spend more than $35 |
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each month on medical costs that: (1) are for a |
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person with a disability or age 60 or older, and (2) |
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are not paid by Medicaid, Medicare or other |
Yes |
No |
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insurance? If yes, send proof. |
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Rent |
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Does anyone get Housing Assistance? |
Yes |
No |
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House payment |
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Property taxes |
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Home insurance |
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Loans |
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Was your home used as collateral? |
Yes |
No |
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If yes, send proof. |
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Child support anyone pays |
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Gas |
Butane or propane |
Electricity |
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Water and sewage |
Garbage |
Phone |
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13.Does any person, organization or agency help anyone on this case pay for the costs listed above (friends, relatives, churches, etc.)?.............................................................................................................................................................
If yes, send proof.
14.If you rent your home, are your heating or cooling costs included in your rent?............................................................
If yes, go to Question 16.
15.How do you heat and cool your home?
16. 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? ..........................................................................
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Elections Division, Secretary of State, P.O. Box 12060, Austin, TX 78711. Phone: 1-800-252-8683.
Agency Use Only: Voter Registration Status
Form H1840
Page 4 / 12-2014-E
Legal information
Your right to be treated fairly:
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www. ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).
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.
You also can contact the Texas HHSC Civil Rights Office. Write to: HHSC Office of Civil Rights, 701 W. 51st St., MC W206, Austin, Texas 78751. Or call toll- free 1-888-388-6332 or 1-877-432-7232 (TTY).
USDA is an equal opportunity provider and employer.
I agree to give HHSC any information necessary to prove statements about my eligibility. I agree that information provided in this application may be used to determine eligibility for myself and other household members for any program administered by HHSC. I will cooperate fully with state or federal personnel to get information from any source to prove the statements I made. I will cooperate fully with state or federal personnel in a quality control review and with Office of Inspector General staff.
I understand that HHSC may adjust my SNAP benefits without further notice because of a cost of living increase in my Social Security or SSI benefits.
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)
Statement of understanding
Checking facts HHSC has about me:
I know that HHSC uses facts about people applying for benefits to decide: (1) who can get benefits, and (2) the amount of benefits. HHSC checks facts with the federal Income and Eligibility Verification System. If any facts don't match, HHSC will check other sources (banks, employers, etc.). If anyone applying for benefits has an immigration registration number, HHSC must check with the U.S. Citizenship and Immigration Services' (USCIS) system. HHSC will not give anyone's facts to USCIS.
In most cases, I can see and get facts HHSC has about me. This includes facts I give HHSC and facts HHSC gets from other sources (medical records, employment records, etc.). I might have to pay to get a copy of these facts. I can ask HHSC to fix anything that is wrong. I do not have to pay to fix a mistake. To ask for a copy or to fix a mistake, I can call 2-1-1 or my local HHSC benefits office.
Telling the truth about my case:
I know that anyone who applies for or gets SNAP must:
•Tell the truth.
•Never trade or sell SNAP benefits, Lone Star Cards or other devices that allow people to get SNAP.
•Never use or have Lone Star Cards or other devices if they don't belong to them.
Anyone who chooses not to tell the truth might:
●Not get SNAP for a year or more.
●Be fined up to $250,000, jailed up to 20 years, or both.
●Lose income tax refunds.
●Be charged with other crimes.
●Have to repay benefits.
●Never get SNAP again.
The same is true if anyone lets someone else use their Lone Star Card.
Reporting changes to my case:
I know that I must report all changes to my case within 10 days of knowing about the change. Changes that must be reported include: (1) my address, (2) money anyone on my case gets (income), (3) costs anyone on my case pays (expenses), (4) things anyone on my case is paying for or owns (resources), and (5) people living in the home.
Getting Social Security or SSI:
I know that my SNAP benefit amount might change without notice if my Social Security or Supplemental Security Insurance (SSI) amounts change.
Form H1840
Page 5 / 12-2014-E
Allowing others to tell or give facts to HHSC:
I know that HHSC uses the facts anyone tells or gives HHSC, including Social Security numbers to:
•Check if that person can get benefits.
•Check that person's facts with computer matching programs and credit reporting agencies.
•Make sure that person is following benefit program rules.
•Help other agencies check if that person can get other benefits.
•Recover benefits that person wasn't supposed to get.
•Share facts about that person: (1) with other state and federal agencies (for example, the Texas Workforce Commission, the Social Security Administration, and the Internal Revenue Service); (2) with law enforcement officials so they can find people on that person's benefits case (the household) who are wanted for fleeing the law; and (3) with federal, state and private claims collecting agencies for food benefit overpayment claims collection action.
(Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036.)
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.
The answers I gave on this SNAP renewal form are true and complete to the best of my knowledge. If my answers are not true, I know that I might be charged with a crime.
Main contact signature |
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Spouse signature |
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Texas driver's license no. (optional): |
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Witness signature (This is needed only if the |
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Person helping with this case |
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main contact signed with an X.) |
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(authorized representative) signature |
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