The Your Texas Benefits renewal form, Form H-1010R updated in December 2012, serves as a critical tool for individuals and families in Texas to continue receiving assistance from various benefit programs. This comprehensive form facilitates the renewal process for benefit recipients, covering a wide array of assistance programs such as SNAP food benefits, TANF cash help, and health care options for children, adults caring for a child receiving TANF benefits, pregnant women, and others seeking to renew their benefits. Beneficiaries have the convenience of renewing their benefits online, by phone, or through traditional methods like fax, mail, or in-person submissions. The form explicitly guides applicants on how to make corrections, the importance of signing and dating the form, and the necessity of attaching required documentation. Additionally, it addresses the capacity for applicants to report any misuse of benefits and provides vital contact information for assistance. This form not only plays a pivotal role in ensuring the continuity of benefits for eligible Texas residents but also emphasizes the state's commitment to supporting its citizens through structured governmental assistance programs.
| Question | Answer |
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| Form Name | Your Texas Benefits Form |
| Form Length | 10 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min 30 sec |
| Other names | your texas benefit app, yourtexasbe, yourtexasbenefits renewal form, my texas benefits forms |
Your Texas Benefits: Renewal Form
Form
December 2012
Case Number: 1234567890
How to Renew |
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Questions |
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You can renew online at |
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Call |
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www.YourTexasBenefits.com. |
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After you pick a language, press 2 to: |
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If you don't want to renew online, fill out this form: |
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Ask question about this form. |
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1. If you need to correct anything on this form: |
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Find where to get help filling out this form. |
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(a) cross it out, and (b) update it. |
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Check the status of this form. |
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2. Sign and date page(s) 9,10 |
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Ask questions about benefit programs. |
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3. Attach the items we need. |
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To learn more about benefits, you also can go to |
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Items are listed next to the questions. |
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www.hhsc.state.tx.us and www.CHIPMedicaid.org. |
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4. Send in this form by fax, mail, or in person: |
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Report waste, fraud, and abuse |
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Fax: |
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If you think anyone is misusing HHSC benefits, call |
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sides |
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Mail: HHSC, P.O. Box 14700, Midland, TX |
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Medicaid for people age 65 or older and for adults |
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In person: At a benefit office. Call |
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who have a disability: |
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near you. |
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If you want to apply for Medicaid for the Elderly and |
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All phone and fax numbers on this form are free to |
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People with Disabilities, call |
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form. |
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call. |
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First Name: |
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Middle initital: |
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Last name: |
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John |
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Doe |
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Home address (street and apartment number) |
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2250 Ridgepoint Dr, APT 123 |
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Austin |
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TX |
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78754 |
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Travis |
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Home phone |
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Cell or daytime phone |
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Mailing address (if different from home address) |
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ZIP |
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Most people applying for benefits must be interviewed. We often interview people on the phone. It helps to know if any of the following reasons make it hard for you to get to a benefits office:
• You live more than 30 miles from the closest benefits |
• Your work or training hours don't allow you to get to a |
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office. |
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benefits office when it's open. |
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• You can't get a ride. |
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• You can't travel because you are age 60 or older, or |
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• The weather is bad. |
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you have a disability. |
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• You are sick. |
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• You are a victim of family violence. |
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• You take care of someone in your home. |
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Do any of the above reasons apply to you? |
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YES |
NO |
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You said you speak Spanish |
during your interview. If you want to speak a different language, |
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which one? |
Do you need an interpreter? We can get one for free. |
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NO |
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Page 1 of 10
Form
December 2012
The people on your case get the benefits marked below. If you want to apply for another program, check the box next to that program
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SNAP food benefits |
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TANF cash help for families |
Health care for: |
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Children |
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Adult caring for a child who |
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gets TANF |
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Pregnant women
People renewing their benefits
Everyone on your benefits case should be listed below.
First name |
Last name |
This person's relationship |
Birth date |
Is this person still |
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to you |
living in your home? |
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John |
Doe |
Self |
01/01/1988 |
YES |
NO |
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Jane |
Doe |
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03/01/1990 |
YES |
NO |
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YES |
NO |
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YES |
NO |
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YES |
NO |
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YES |
NO |
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YES |
NO |
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YES |
NO |
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YES |
NO |
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YES |
NO |
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List anyone who lives with you, but isn't listed above.
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This person's |
Social |
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If not a U.S. citizen, tell us: |
Is this |
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Name |
Male or |
Birth |
U.S. |
Immigrant |
Date this |
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relationship to |
Security |
person |
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person entered |
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(first and last) |
female? |
you |
number |
date |
citizen |
registration |
applying for |
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number |
the United |
benefits? |
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States |
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M |
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YES |
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YES |
NO |
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N |
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NO |
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M |
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YES |
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YES |
NO |
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N |
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NO |
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Other facts
Is anyone who has been charged with or convicted of a felony fleeing the police? Or has anyone broken a rule of their probation or parole?
If yes, who? __________________________________________________
YES NO
Has anyone been convicted of a felony for conduct that: (1) took place after August 22, 1996, and
(2) involved illegal drugs?
YES NO
If yes, who? ___________________________________________________
Page 2 of 10
Form |
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December 2012 |
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Is anyone getting cash help, food, or |
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YES |
NO |
If yes, who? __________________________________ Which state? ______________________ |
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Is anyone living in the homes: (1) age 18 years or older, and (2) a student? |
YES |
NO |
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Is anyone in your home pregnant? |
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If yes, who? _____________________________________________ |
YES |
NO |
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Due date (mm/dd/yyyy) ______________Number of babies expected_______ |
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What is the first and last name of the unborn child's father? |
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First: _______________________________ Last: ___________________________ |
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Does anyone have a disability? |
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YES |
NO |
If yes, who? __________________________________ |
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Is anyone an unaccompanied refugee minor? |
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This means a person is: (1) not living with a relative, (2) age 18 or younger, and (3) a refugee. |
YES |
NO |
If yes, who? __________________________________ |
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Health insurance
Does anyone have health insurance other than Medicare, Medicaid, or CHIP? If yes, who? __________________________________
Send a copy (front and back) of the insurance card.
YES NO
Things you are paying for or own
Does anyone own or is anyone paying for a: car, truck, boat, motorcycle, or other vehicle? If yes, give facts below:
YES NO
Year
Make
Model
Monthly Payment
Monthly Insurance
Payment
Money still owed
$
$
$
$
$
$
$
$
$
Does anyone have cash, bank accounts, homes, or other property? |
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If yes, write the amount or value below. Write “none” if no one has any of these items. |
YES NO |
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Send the most recent statement for all accounts |
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Cash: $______________ |
Other: $_____________ |
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Bank accounts: All savings $__________ |
All Checking $_____________ |
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Property if you don't live on it: $___________ |
Homes if you don't live in them: $__________ |
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Page 3 of 10
Form
December 2012
Money coming into your home
List all money everyone living in your home gets or will get. Include money from job or
Send pay stubs or statement from the last 60 days. If you work for yourself, attach proof of money you get (income), taxes and job costs. Add more pages if you need more room.
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Person, company, or |
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Amount you get |
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agency paying the |
Hours |
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Name of person |
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paid (before taxes |
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money. If you were |
worked |
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How often paid? |
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getting this money |
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and deductions |
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working for yourself, |
per week |
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write “self.” |
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are taken out) |
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no longer working |
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once a week |
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every 2 weeks |
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once a month |
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daily |
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other |
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no longer working |
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once a week |
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every 2 weeks |
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once a month |
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daily |
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other |
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no longer working |
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once a week |
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every 2 weeks |
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once a month |
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daily |
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other |
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no longer working |
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once a week |
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every 2 weeks |
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once a month |
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daily |
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other |
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Housing costs
Does anyone pay any of the costs listed below for the home they are living in? Or for a home they plan to return to?
Rent or home payment $ _____ |
Natural gas/propane $ _____ |
Taxes on home $ _____ |
Phone $ _____ |
Water or sewer $ _____ |
Electricity $ _____ |
Insurance on home $ _______ |
TV cable $ _____ |
Other $ _____ |
YES NO
Send statements or bills showing your name and address.
Costs for people who depend on you
Does anyone pay child care costs so they can work, look for work, go to training or go to school? |
YES |
NO |
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If yes, $ _________ |
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Send statements or bills showing your name and address. |
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Does anyone pay child support payments, medical bills, and health insurance for a child outside |
YES |
NO |
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your home? |
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If yes, $ _________ |
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Send statements or bills showing your name and address. |
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Does anyone pay for costs for people with disabilities or adults who can't take care of themselves? |
YES |
NO |
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If yes, $ _________ |
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Send statements or bills showing your name and address. |
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Page 4 of 10
Form |
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December 2012 |
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Other costs |
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Does anyone in the home pay alimony? |
YES |
NO |
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If yes, how much do you pay each month? $ _________ |
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Does anyone in the home pay credit card costs? |
YES |
NO |
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If yes, how much do you pay each month? $ _________ |
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Does anyone in the home pay other regular monthly costs? |
YES |
NO |
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If yes, how much do you pay each month? $ _________ |
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Does another person not on your case help anyone on your case pay for any of the above costs? |
YES |
NO |
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If yes, who? ______________________________ |
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Medical costs |
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Does anyone in the home age 60 or older, or anyone with a disability, pay medical costs: doctor, hospital, or medicine?
If yes, send bills, receipts, or statements.
YES NO
Legal Information
Discrimination: |
Social Security numbers: |
In accordance with Federal law and U.S. Department of Agriculture |
You only need to give the Social Security |
(USDA) and U.S. Department of Health and Human Services (HHS) |
numbers (SSN) for people who want benefits. |
policy, this institution is prohibited from discriminating on the basis of |
Giving or applying for an SSN is voluntary; |
race, color, national origin, sex, age, or disability. Under the Food |
however, anyone who doesn't apply for an SSN |
Stamp Act and USDA policy, discrimination is prohibited also on the |
or doesn't give an SSN can't get benefits. If |
basis of religion or political beliefs. |
you don't have an SSN, we can help you apply |
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for one if you are a U.S. citizen or a legal |
To file a complaint of discrimination, contact USDA or HHS. Write |
immigrant. You must be a U.S. citizen or a |
USDA, Director, Office of Civil Rights, 1400 Independence Avenue, |
legal immigrant to get an SSN. You can get |
S.W., Washington D.C. |
benefits for your children if they have SSNs |
or (202) |
and you don't. We will not give SSNs to the U. |
Young Street #1169, Dallas, TX |
S. Immigration and Citizenship Services. We |
will use SSNs to check the amount of money |
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equal opportunity providers and employers. |
you get (income), if you can get benefits, and |
You also can contact the Texas HHSC Civil Rights Office. Write to: |
the amount of benefits you can get. (7 C.F.R |
HHSC Office of Civil Rights, 701 W. 51st St., MC W206, Austin, |
273.6 for food benefits; 45 C.F.R 205.52 for |
Texas 78751. Or call |
TANF; and 42 C.F.R 435.910 for health care.) |
(TTY). |
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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
Page 5 of 10
Form
December 2012
Statement of Understanding
Read the box marked “All Benefit Programs.” Then read the boxes about each of the benefits anyone is applying for.
All Benefit Programs
Facts HHSC has about me |
I might have to pay to get a copy of these facts. I can ask |
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HHSC uses facts about people applying for benefits to |
HHSC to fix anything that is wrong. I do not have to pay to |
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decide: (1) who can get benefits, and (2) the amount of |
fix a mistake. To ask for a copy or to fix a mistake, I can |
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benefits. |
call |
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HHSC checks facts with the federal Income and Eligibility |
Keeping my facts private |
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Verification System. If any facts don't match, HHSC will |
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check other sources (banks, employers, etc.). |
HHSC will keep my facts private if they were collected: |
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If anyone applying for benefits has an immigration |
• By HHSC staff or contracted provider staff. |
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registration number, HHSC must check with the U.S. |
• To find out if I can get state benefits. |
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Citizenship and Immigration Service (USCIS) system. |
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HHSC will not give anyone's facts to USCIS. |
HHSC can share facts about me: |
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In most cases, I can see and get facts HHSC has about |
• When needed for me to get state health care |
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benefits. |
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me. This includes facts I give HHSC and facts HHSC gets |
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from other sources (medical records, employment |
• With phone and utility companies. They will find out |
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records, etc.). |
if my bill amount can be lowered. HHSC will give |
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them my name, address, and phone number. |
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SNAP food benefits: (SNAP)
Read this box if you are applying for food benefits.
Telling the truth |
Facts anyone tells or gives HHSC |
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HHSC uses the facts anyone tells or gives HHSC, |
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Anyone who applies for or gets SNAP must: |
including Social Security numbers to: |
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• Tell the truth. |
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Check if that person can get benefits. |
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• Never trade or sell SNAP benefits, Lone Star |
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Make sure that person is following benefit |
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Cards, or other devices that allow people to get |
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program rules. |
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SNAP. |
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Help other agencies check if that person can get |
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• Never use or have Lone Star Cards or other |
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other benefits. |
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devices if they don't belong to that person. |
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Recover benefits that person wasn't supposed to |
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get. |
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• Share facts about that person with other state |
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Anyone who chooses not to tell the truth might: |
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and federal agencies (for example, the Texas |
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Workforce Commission, the Social Security |
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• Not get SNAP for a year or more. |
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Administration, and the Internal Revenue |
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Service). |
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• Be fined up to $250,000, jailed up to 20 years, |
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Share facts with law enforcement officials so |
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or both. |
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they can find people on that person's benefits |
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• Lose income tax refunds. |
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case (the household) who are wanted for |
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• Be charged with other crimes. |
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fleeing the law. |
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• Have to repay benefits. |
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• |
Share facts with federal, state, and private |
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• Never get SNAP again. |
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claims collecting agencies for food benefit |
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The same is true if anyone lets someone else use their |
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overpayment claims collection action. |
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Check that person's facts with computer |
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Lone Star Card. |
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matching programs and credit reporting |
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agencies. |
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Page 6 of 10
Form
December 2012
Medicaid:
Read this box if you are applying for Medicaid benefits.
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.
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.
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.
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.
TANF cash help for families (TANF):
Read this box if you are applying for TANF.
Child support or alimony |
If I give false information |
I agree to: |
If I choose to not tell the truth, I might: |
• Let the state keep any child support or alimony |
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money owed to anyone during the time they get |
• Be charged with and punished for a crime. (This |
TANF. |
could include going to prison for up to 10 years |
• Let the state keep this money after TANF |
or community supervision.) |
benefits end, if the TANF amount anyone got |
• Have to repay benefits. |
still needs to be paid off. |
• Never get TANF again. |
• Tell HHSC about money anyone gets. |
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• Work with HHSC to get this money; if I don't, I |
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am breaking the law. |
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The state will only keep the amount allowed by law. |
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Page 7 of 10
Form
December 2012
People helping you
Did someone help you fill out this form?
If yes, tell us about that person:
Name |
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YES
NO
Address
Authorized Representative
An Authorized Representative can act for the person applying for benefits by:
•Giving and getting facts related to the application.
•Taking any action needed to complete the application process. This includes appealing an HHSC decision.
•Taking any action related to getting benefits. This includes reporting changes.
Do you want to give someone the right to act for you to be your authorized representative? If yes, tell us about that person (the authorized representative)
Name of authorized representative
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YES
NO
*** You must sign and date the next page.***
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:
Agency Use Only: Voter Registration Status
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Agency registered |
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Client declined |
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Agency transmitted |
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Client to mail |
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Mailed to client |
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Other |
Agency staff signature
Page 8 of 10
Form
December 2012
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)amount of benefits.
My answers are true: 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.
Sign here to show you agree:
Person applying or the authorized representative for the person applying for benefits:
Sign here |
Date |
Witness only needed if anyone above signed with an “X” or other mark:
Sign here |
Date |
Printed name of witness
Parent, guardian, or power of attorney for the person applying you must give proof of this right:
Sign here |
Date |
Phone Number
Page 9 of 10
Form
December 2012
Help you can get without filling out this form
Services in your Area |
Family Violence Program |
Alcohol and Drug Abuse |
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Prevention Program |
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Do you need help finding |
Are you afraid for your children's or |
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your safety? |
Do you or someone you know want to |
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services? |
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stop using alcohol or drugs? |
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Call |
You can get help to: |
You can get help: |
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• Getting a ride to a safe |
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place. |
• Quitting. |
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After you pick a language, press 1. |
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• Finding shelter, legal help, |
• Dealing with a crisis. |
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and a job. |
• Keeping others from using drugs |
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Getting counseling. |
or alcohol. |
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Call the hotline anytime at |
Call |
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(TTY |
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Texas Workforce Network |
Adult Education and Family |
Health Insurance Premium |
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Literacy Program |
Payment Program |
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Are you looking for work? |
Do you want help learning to |
Do you need help paying for your health |
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You can get help: |
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read or getting a GED? Do you |
insurance? |
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• Applying for a job. |
need help with job skills? Or |
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learning to speak English? |
Call |
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Finding a job. |
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Or write: |
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Call |
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Texas Health and Human |
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Workforce Center. |
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Services Commission |
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PO Box 201120 |
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Austin, Texas |
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Family Planning |
Women, Infants and Children |
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program (WIC) |
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Do you need help with family |
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planning? |
Are you pregnant or a new |
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Men and women can get help with: |
mother? |
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Birth control supplies. |
You can get help: |
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Other health care. |
1. |
Getting food for you and your |
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children. |
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Call |
2. |
Getting vaccines. |
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Women with low income might be |
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able to get free services in the |
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Call |
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Women's Health Program. To learn |
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more, call |
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Page 10 of 10