Texas Form H1869 PDF Details

Whether you are a property owner, landlord, tenant or real estate agent making transactions in Texas, Form H1869 is an important document. This form is needed for many different types of real estate transactions and must be completed correctly to fully protect the interests of all parties involved. In this blog post we will discuss what Texas Form H1869 covers and how to properly fill out this essential form both accurately and efficiently.

QuestionAnswer
Form NameTexas Form H1869
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesH1869 dax number t texas health and human services form

Form Preview Example

Texas Health and Human

Form H1869

Services Commission

December 2012

Renewal for Health Care Benefits

(First Name Last Name)

(Address Line 1)

(Address Line 2)

(City, TX ZIP)

You must be age 21 or 22 to get this state health coverage.

Case Number

Office Address

HHSC

P.O. Box 14700 Midland, TX 79711-4700 Telephone: 2-1-1 or 1-877-541-7905

After you pick a language, press 2.

You can renew benefits by going to www.YourTexasBenefits.com or you can fill out the form below.

Are you still going to college, university, medical or dental school, or technical institute?..............................................

If yes:

1.Fill out this renewal form if facts you gave us in the past year has changed.

Yes

No

2.Fill out the attached School Enrollment Verification form or send a school form that will prove that you are in school. Even if the information is the same, you need to send us proof that you are still going to school.

3.Send us all forms in the pre-paid envelope.

Name (first, middle, last)

Address

 

City

 

 

State

ZIP Code

County

 

 

 

 

 

 

 

 

 

Mailing Address

 

City

 

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

Area code and phone number

 

Are you pregnant?

 

Do you have health insurance?

Home:

Other:

Yes

No

 

Yes

No

 

 

 

 

 

 

 

Name of insurance company

 

 

 

Insurance company area code and phone number

 

 

 

 

 

 

 

 

 

Money you get and things you own (income and resources):

Tell us how much money you make before taxes. Include money you earn from jobs, money you get from unemployment insurance or Social Security, or any type of money you get on a regular basis. (Add a page if you need more room.)

Employer Name or Source of Income

How much?

 

How often?

 

 

 

$

weekly

every 2 weeks

twice a month

monthly

 

 

 

 

 

 

 

 

 

$

weekly

every 2 weeks

twice a month

monthly

 

 

 

 

 

 

 

 

 

$

weekly

every 2 weeks

twice a month

monthly

 

 

 

 

 

 

 

 

Do you have more than $10,000 in bank accounts, cash or anywhere else?

 

Yes

No

 

Do you have 2 or more cars, trucks or other vehicles worth more than $10,000 each?

 

Yes

No

 

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

Information you provide in connection with this application is subject to verification by HHSC and other state and federal agencies. Your signature below authorizes release of such information to HHSC and to third parties HHSC may contact to verify the information.

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.

Signature

Date

 

 

Form H1869

Page 2/12-2012

Your Rights

You have the right to be treated fairly and equally regardless of your race, color, religion, national origin, gender, political beliefs or disability consistent with state and federal law and to file a complaint if you feel you have been discriminated against.

You have the right to request a review of your case if you are: (1) not notified in writing within 30 days from the date your renewal application is filed of the decision regarding your renewal application; (2) denied coverage through this program; or (3) dissatisfied with any other decision that affects your receipt of health care benefits.

Other Important Information

This is not a Medicaid program. To apply for Medicaid or other state benefits, you must complete an application at your local HHSC benefits office. Call 2-1-1 to find an office near you.

Agency Use Only: Voter Registration Status

Already registered

Agency staff signature

Client declined

Agency transmitted

Client to mail

Mailed to client

Other