Agency staff signature:
Citizenship: To show proof of U.S. citizenship you can send copies of 1) a U.S. passport, 2) a Certificate of Naturalization or 3) a Certificate of U.S. Citizenship. If you do not have one of those, you can send us copies of a birth certificate and current driver’s license with photo or I.D. card with photo. For people born in Texas, we may be able to get the birth certificate electronically and you will not need to provide it. Call 2-1-1 to learn about other documents that are accepted as proof of citizenship. You do not have to prove citizenship for anyone living in your home who is not asking for benefits.
Immigration: You can send us copies of one of the following to show proof of immigration status: 1) an alien registration card or 2) a document from the Bureau for Citizenship and Immigration Services (formerly INS).
You do not have to give us facts about immigration status for anyone living in your home who is not asking for benefits. You can apply and get benefits for eligible family members, even if you have people living in your home who are not eligible because of immigration status. If you or members of your family use Medicaid, the Children's Health Insurance Program (CHIP) or food stamps, it will not affect you or your family members' immigration status or ability to get a green card. If you or your family members use long-term institutional care, such as a nursing home, immigration status could be affected. Talk to an agency that helps immigrants with legal questions before you apply. Refugees and people granted asylum can use any benefits, including cash assistance, without hurting their chances of getting a green card or U.S. citizenship.
*Social Security numbers: You only need to give us Social Security number (SSN) for the person who is applying for benefits. If you do not have an SSN, we can help you apply for one. Before you can get benefits, you must give us your SSN or be applying for one. 42 U.S.C. §405(a)(2)(C)(i) authorizes us to require SSNs from the people applying for benefits under the Texas Women’s Health Program.
We will not share your SSN with the Bureau of Citizenship and Immigration Service (formerly INS). You will not have to provide a SSN for anyone living in your home who is not asking for benefits.
We use SSNs to check the amount of money you get (your income) and the income of people living in your home. We also use these numbers to verify facts about you through other agencies (such as the Texas Workforce Commission, the Social Security Administration, the Internal Revenue Service, credit reporting agencies), and to get back benefits you were not supposed to get. We may also share SSNs with phone and electric utility companies to help them find out if they can lower your bills. We also may share SSNs with other groups to see if you can get other benefits based on need.
*Race, ethnicity and sex: We ask you to tell us about your race/ethnic background and sex but you do not have to give those facts to us. The same goes for people living in your home. We use those facts to make sure we provide benefits without regard to race, color or national origin. Whether you give us those facts or not, it will not affect our decision on whether you can get benefits or how much you get in benefits.
Discrimination: In accordance with state law and regulation, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, or religion. If you feel you have been discriminated against, you may contact HHSC Civil Rights by writing to:
HHSC, Director, HHSC Civil Rights Office
701 W. 51st St., Suite 104, MC W-206
Austin, TX, 78751
Or you can fax your letter to the HHSC Civil Rights Office at 1-512- 438-5885.
Or you can call 1-888-388-6332 (voice) or 1-512- 438-2960 (TDD).
WIC: Documents we accept as proof of receiving WIC include 1) WIC Verification of Certification letter or 2) active WIC voucher/EBT Shopping List.
Money everyone in your home gets (income) - send proof such as:
Copy of checks.
Statement from employer.
Statement from the person who gives the money. The statement should include that person’s name, address, phone number, signature, and date.
Costs everyone in your home pays - send proof such as:
Copies of checks.
Statement from the person you pay. The statement should include that person’s name, address, phone number, signature, date, and when and how often you pay.
Copy of district clerk record.
Questions: Call us toll free at 2-1-1 or 1-877-541-7905.
Copy all items of proof and fax them with the front page of this form to 1-866-993-9971 (toll-free).
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