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

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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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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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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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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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Form H-1010R

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
	HHSC uses facts about people applying for benefits to	HHSC to fix anything that is wrong. I do not have to pay to
	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
	benefits.	call 2-1-1 or my local HHSC benefits office.
	HHSC checks facts with the federal Income and Eligibility	Keeping my facts private
	Verification System. If any facts don't match, HHSC will
	check other sources (banks, employers, etc.).	HHSC will keep my facts private if they were collected:
	If anyone applying for benefits has an immigration	• By HHSC staff or contracted provider staff.
	registration number, HHSC must check with the U.S.	• To find out if I can get state benefits.
	Citizenship and Immigration Service (USCIS) system.
	HHSC will not give anyone's facts to USCIS.	HHSC can share facts about me:
	In most cases, I can see and get facts HHSC has about	• When needed for me to get state health care
	In most cases, I can see and get facts HHSC has about	benefits.
	me. This includes facts I give HHSC and facts HHSC gets	benefits.
	me. This includes facts I give HHSC and facts HHSC gets
	from other sources (medical records, employment	• With phone and utility companies. They will find out
	records, etc.).	if my bill amount can be lowered. HHSC will give
		them my name, address, and phone number.

SNAP food benefits: (SNAP)

Read this box if you are applying for food benefits.

Telling the truth	Facts anyone tells or gives HHSC
Telling the truth
	HHSC uses the facts anyone tells or gives HHSC,
Anyone who applies for or gets SNAP must:	including Social Security numbers to:
• Tell the truth.	•	Check if that person can get benefits.
• Never trade or sell SNAP benefits, Lone Star	•	Make sure that person is following benefit
Cards, or other devices that allow people to get		program rules.
SNAP.	•	Help other agencies check if that person can get
• Never use or have Lone Star Cards or other		other benefits.
devices if they don't belong to that person.	•	Recover benefits that person wasn't supposed to
		get.
	• Share facts about that person with other state
Anyone who chooses not to tell the truth might:		and federal agencies (for example, the Texas
Anyone who chooses not to tell the truth might:		Workforce Commission, the Social Security
		Workforce Commission, the Social Security
• Not get SNAP for a year or more.		Administration, and the Internal Revenue
• Not get SNAP for a year or more.		Service).
• Be fined up to $250,000, jailed up to 20 years,		Service).
• Be fined up to $250,000, jailed up to 20 years,	•	Share facts with law enforcement officials so
or both.	•	Share facts with law enforcement officials so
or both.		they can find people on that person's benefits
• Lose income tax refunds.		they can find people on that person's benefits
• Lose income tax refunds.		case (the household) who are wanted for
• Be charged with other crimes.		case (the household) who are wanted for
• Be charged with other crimes.		fleeing the law.
• Have to repay benefits.		fleeing the law.
• Have to repay benefits.	•	Share facts with federal, state, and private
• Never get SNAP again.	•	Share facts with federal, state, and private
• Never get SNAP again.		claims collecting agencies for food benefit
		claims collecting agencies for food benefit
The same is true if anyone lets someone else use their		overpayment claims collection action.
The same is true if anyone lets someone else use their	•	Check that person's facts with computer
Lone Star Card.	•	Check that person's facts with computer
Lone Star Card.		matching programs and credit reporting
		matching programs and credit reporting
		agencies.
	(Food Stamp Act of 1977, as amended, 7 U.S.C.
	2011-2036.)

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Form H-1010R

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
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.
• Work with HHSC to get this money; if I don't, I
am breaking the law.
The state will only keep the amount allowed by law.

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Form H-1010R

December 2012

People helping you

Did someone help you fill out this form?

If yes, tell us about that person:

Name
	(		)	-
Relationship or organization		Phone

YES

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

YES

*** 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

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: 1-800-252-8683.

Agency Use Only: Voter Registration Status

Agency registered

Client declined

Agency transmitted

Client to mail

Mailed to client

Other

Agency staff signature

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Form H-1010R

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

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Form H-1010R

December 2012

Help you can get without filling out this form

Services in your Area		Family Violence Program		Alcohol and Drug Abuse
Services in your Area				Prevention Program
				Prevention Program
Do you need help finding		Are you afraid for your children's or
Do you need help finding		your safety?		Do you or someone you know want to
services?		your safety?		Do you or someone you know want to
services?				stop using alcohol or drugs?
				stop using alcohol or drugs?
Call 2-1-1 (if you can't connect, call		You can get help to:		You can get help:
1-877-541-7905).		• Getting a ride to a safe		You can get help:
1-877-541-7905).			place.	• Quitting.
After you pick a language, press 1.			place.	• Quitting.
After you pick a language, press 1.		• Finding shelter, legal help,		• Dealing with a crisis.
		• Finding shelter, legal help,		• Dealing with a crisis.
			and a job.	• Keeping others from using drugs
		•	Getting counseling.	or alcohol.
		Call the hotline anytime at		Call 1-877-966-3784
		1-800-799-7233 (1-800-799-SAFE)		(1-877-9-NO DRUG).
		(TTY 1-800-787-3224).

Texas Workforce Network		Adult Education and Family		Health Insurance Premium
Texas Workforce Network		Literacy Program		Payment Program
		Literacy Program		Payment Program
Are you looking for work?		Do you want help learning to		Do you need help paying for your health
You can get help:		Do you want help learning to		Do you need help paying for your health
You can get help:		read or getting a GED? Do you		insurance?
		read or getting a GED? Do you		insurance?
• Applying for a job.		need help with job skills? Or
• Applying for a job.		learning to speak English?		Call 1-800-440-0493.
•	Finding a job.	learning to speak English?		Call 1-800-440-0493.
•	Finding a job.			Or write:
				Or write:
Call 2-1-1 to find a Texas		Call 1-800-441-7323
Call 2-1-1 to find a Texas		(1-800-441-READ).		Texas Health and Human
Workforce Center.		(1-800-441-READ).		Texas Health and Human
Workforce Center.				Services Commission
				Services Commission
				TMHP-HIPP
				PO Box 201120
				Austin, Texas 78720-1120

Family Planning		Women, Infants and Children
		program (WIC)
Do you need help with family
planning?		Are you pregnant or a new
Men and women can get help with:		mother?
•	Birth control supplies.	You can get help:
•	Other health care.	1.	Getting food for you and your
		children.
Call 2-1-1 to find a clinic.		2.	Getting vaccines.
Women with low income might be
able to get free services in the			Call 1-800-942-3678.
Women's Health Program. To learn
more, call 1-866-993-9972.

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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