Your Texas Benefits Form – Fill Out and Use This PDF

Your Texas Benefits Form – Fill Out and Use This PDF

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Your Texas Benefits: Renewal Form

Form H-1010R

December 2012

Case Number: 1234567890

How to Renew

Questions

You can renew online at

Call 2-1-1 or 1-877-541-7905.

www.YourTexasBenefits.com.

After you pick a language, press 2 to:

If you don't want to renew online, fill out this form:

Ask question about this form.

1. If you need to correct anything on this form:

Find where to get help filling out this form.

(a) cross it out, and (b) update it.

Check the status of this form.

2. Sign and date page(s) 9,10

Ask questions about benefit programs.

3. Attach the items we need.

To learn more about benefits, you also can go to

Items are listed next to the questions.

www.hhsc.state.tx.us and www.CHIPMedicaid.org.

4. Send in this form by fax, mail, or in person:

Report waste, fraud, and abuse

Fax: 1877-447-2839. If the form is 2-sided fax both

If you think anyone is misusing HHSC benefits, call

sides

1-800-436-6184.

Mail: HHSC, P.O. Box 14700, Midland, TX 79711-9907

Medicaid for people age 65 or older and for adults

In person: At a benefit office. Call 2-1-1 to find one

who have a disability:

near you.

If you want to apply for Medicaid for the Elderly and

All phone and fax numbers on this form are free to

People with Disabilities, call 2-1-1. Ask for a different

form.

call.

First Name:

Middle initital:

Last name:

John

Doe

Home address (street and apartment number)

City

State

ZIP

County

2250 Ridgepoint Dr, APT 123

Austin

78754

Travis

Home phone

Cell or daytime phone

234-234-3456

Mailing address (if different from home address)

City

State

ZIP

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
office.		benefits office when it's open.
• You can't get a ride.		• You can't travel because you are age 60 or older, or
• The weather is bad.		you have a disability.
• You are sick.		• You are a victim of family violence.
• You take care of someone in your home.

Do any of the above reasons apply to you?			YES	NO

You said you speak Spanish	during your interview. If you want to speak a different language,
which one?	Do you need an interpreter? We can get one for free.		YES	NO

Page 1 of 10

T-01010-1234567890

Form H-1010R

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

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
First name	Last name	to you	Birth date	living in your home?
		to you		living in your home?

John	Doe	Self	01/01/1988	YES	NO
John	Doe	Self	01/01/1988
Jane	Doe		03/01/1990	YES	NO
				YES	NO
				YES	NO

				YES	NO

				YES	NO

				YES	NO
				YES	NO
				YES	NO

				YES	NO

List anyone who lives with you, but isn't listed above.

		This person's	Social			If not a U.S. citizen, tell us:		Is this
Name	Male or	This person's	Social	Birth	U.S.	Immigrant	Date this	Is this
		relationship to	Security				Date this	person
		relationship to	Security				person entered	person
(first and last)	female?	you	number	date	citizen	registration	person entered	applying for
						number	the United	benefits?
						number	States



	M				YES			YES	NO
	N				NO

	M				YES			YES	NO
	N				NO

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? ___________________________________________________

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T-01010-1234567890

Form H-1010R
December 2012

Is anyone getting cash help, food, or health-care benefits from another state?
	YES	NO
If yes, who? __________________________________ Which state? ______________________

Is anyone living in the homes: (1) age 18 years or older, and (2) a student?	YES	NO

Is anyone in your home pregnant?
If yes, who? _____________________________________________	YES	NO
	YES	NO
Due date (mm/dd/yyyy) ______________Number of babies expected_______
What is the first and last name of the unborn child's father?
First: _______________________________ Last: ___________________________

Does anyone have a disability?
	YES	NO
If yes, who? __________________________________

Is anyone an unaccompanied refugee minor?
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? __________________________________

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?
If yes, write the amount or value below. Write “none” if no one has any of these items.		YES NO

Send the most recent statement for all accounts
Cash: $______________	Other: $_____________
Bank accounts: All savings $__________	All Checking $_____________
Property if you don't live on it: $___________	Homes if you don't live in them: $__________

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T-01010-1234567890

Form H-1010R

December 2012

Money coming into your home

List all money everyone living in your home gets or will get. Include money from job or self-employment, unemployment benefits, Social Security, Supplemental Security Income (SSI), child support, student financial aid, Veteran's Benefits, or cash loans.

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.

	Person, company, or				Amount you get
	agency paying the	Hours			Amount you get
Name of person	agency paying the	Hours			paid (before taxes
Name of person	money. If you were	worked	How often paid?		paid (before taxes
getting this money	money. If you were	worked	How often paid?		and deductions
getting this money	working for yourself,	per week			and deductions
	write “self.”				are taken out)
	write “self.”

			no longer working	once a week
			no longer working	once a week
			every 2 weeks	once a month
			every 2 weeks	once a month
			daily	other
			daily	other
			no longer working	once a week


			every 2 weeks	once a month
			every 2 weeks	once a month
			daily	other
			daily	other


			no longer working	once a week
			every 2 weeks	once a month
			every 2 weeks	once a month
			daily	other
			daily	other


			no longer working	once a week
			every 2 weeks	once a month
			every 2 weeks	once a month
			daily	other
			daily	other

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
If yes, $ _________	YES	NO
If yes, $ _________
Send statements or bills showing your name and address.

Does anyone pay child support payments, medical bills, and health insurance for a child outside	YES	NO
your home?
If yes, $ _________
Send statements or bills showing your name and address.

Does anyone pay for costs for people with disabilities or adults who can't take care of themselves?	YES	NO
If yes, $ _________	YES	NO
If yes, $ _________
Send statements or bills showing your name and address.

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T-01010-1234567890

Form H-1010R
December 2012
Other costs

Does anyone in the home pay alimony?	YES	NO
	YES	NO
If yes, how much do you pay each month? $ _________

Does anyone in the home pay credit card costs?	YES	NO
	YES	NO
If yes, how much do you pay each month? $ _________

Does anyone in the home pay other regular monthly costs?	YES	NO
	YES	NO
If yes, how much do you pay each month? $ _________

Does another person not on your case help anyone on your case pay for any of the above costs?	YES	NO
	YES	NO
If yes, who? ______________________________

Medical costs

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
	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. 20250-9410 or call (800) 795-3272 (voice)	benefits for your children if they have SSNs
or (202) 720-6382 (TTY). Write HHS, Office for Civil Rights, 1301	and you don't. We will not give SSNs to the U.
Young Street #1169, Dallas, TX 75202-5433. Or call	S. Immigration and Citizenship Services. We
1-214-767-4056 or 1-214-767-8940 (TTY). USDA and HHS are	will use SSNs to check the amount of money
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 toll-free 1-888-388-6332 or 1-877-432-7232	TANF; and 42 C.F.R 435.910 for health care.)
(TTY).

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 long-term care (Medicaid for the Elderly and People with Disabilities) or cash help (TANF) could affect your immigration status and your chances of getting a Permanent Resident Card (green card). Getting other benefits will not affect your immigration status and your chances of getting a Permanent Resident Card. You might want to talk to an agency that helps immigrants with legal questions before you apply. If you are a refugee or have been given asylum, getting benefits will not affect your chances of getting a Permanent Resident Card or becoming a citizen.

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T-01010-1234567890

Question	Answer
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

SNAP food benefits

TANF cash help for families

Health care for:

Adult caring for a child who

Adult caring for a child who