Case Number: 1018149697

11/22/2023

Need Help? Call 2-1-1

or for out of the state callers,
call 1-877-541-7905
Fax: 1-877-447-2839
Ms. Maria Bautista
4110 Park ST Mail: Texas Health and Human Services
Greenville TX 75401-4915 Commission
PO Box 149024
Austin Texas 78714-9024
If you have a hearing or speech disability,
call 7-1-1 or any relay service.

To find out if you can get or keep getting benefits, we need more facts from you:
You are getting this packet because either: (1) you applied for benefits, (2) you reported a change to your case, or (3)
we must check your income to see if you can still get benefits.
Inside this packet you will find:
• A list of the items we need from you.
• A pre-paid envelope.

You also might find other forms you can fill out and send to us.

Send us the items by 12/04/2023

If you need help, call us at 2-1-1 or 877-541-7905. After you pick a language, press 2. We can take your call
Monday to Friday, 8 a.m. to 6 p.m. Central Time.
For help or questions about your Lone Star Card account, call 1-800-777-7328 (7EBT).
You still need to send us the items by this due date.

If you don't send us your items by this date,

you might not get benefits or your benefits might end.

There are 4 ways to send us the items we need:

Pick one of these ways to send the items back to us:
• YourTexasBenefits.com: You can upload your items online.

• Your Texas Benefits Mobile App: You can upload your items using the mobile app.
The app is free to download in the Google Play and Apple iTunes stores.

• Mail: Mail this letter and the items we need in the pre-paid envelope that came in this packet.

•
Fax: Fax this letter and the items we need to 1-877-447-2839.

Don't forget:
• Put your case number on everything you send us.
• If you send us a letter or statement showing proof of facts we need, make sure the person who writes it includes:
(1) their name, (2) their address, (3) their phone number, (4) the date they wrote it, and (5) their signature.

Form 1020 Page 1 of 4

12/2022 T-01020-0775703866
 Benefit programs affected and due date:

Program EDG number Due date

For Medical Assistance: 717448591 12/4/23

For Medical Assistance: 714577070 12/4/23

For Medical Assistance: 704979543 12/4/23

For Food Stamp benefits: 603305055 12/4/23

If you're afraid that giving us facts about someone could cause harm (physical or emotional) to you or
your child:
If you're applying for or renewing Medicaid or CHIP benefits, you might not need to give us facts about that
person. You might be able to get the "Family Violence Exemption."
Let us know if you're afraid to give facts about someone:

• Phone: Call 2-1-1 or 1-877-541-7905 (after picking a language, press 2).

• Mail: TEXAS HEALTH AND HUMAN SERVICES COMMISSION,P O Box 149024,

Austin, Texas 78714-9024
• In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 or
1-877-541-7905 (after picking a language, press 1).
• Fax: 1-877-447-2839.

Form 1020 Page 2 of 4

12/2022 T-01020-0775703866
 LIST OF INFORMATION NEEDED AND/OR ACTION REQUIRED:
Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof
Maria Bautista Food Stamps Provide verification of all money you earn from Contact the Employer
Medicaid any source. Greenville Independent School Data Broker
District Employer.
Form 1028 Employment Verification
Form 2583 Choices Information Transmittal
Recent checks, stubs, or earnings statements.
TWC inquiry
Workshop or State School reimbursement officer
Maria Bautista Food Stamps Provide verification of the following missing pay Employer.
period amounts from Greenville Independent Form 1028 Employment Verification
School District: 11/12/2023; 10/27/2023; Recent checks, stubs, or earnings statements.
10/12/2023; 09/27/2023
Maria Bautista Food Stamps Provide verification that you lost your job. Employer
Employment records
Form 1028 Employment Verification

Form 1020-A Page 3 of 4

12/2022 T-01020-0775703866
 Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024

Case Number:1018149697

The enclosed Missing Information form (Form 1020) includes a list of documents you need to send to us
so we can determine your eligibility for services.

See page 1 to find out how to send us your forms.

El formulario adjunto de información faltante (Formulario 1020) incluye una lista de documentos que
usted necesita enviarnos para que podamos determiner si usted reúne los requisitos para los servicios.

Vea la página 1 para saber cómo enviarnos sus documentos.

Form 1020B Page 4 of 4

12/2022 T-01020-0775703866
 TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

Date: 11/22/2023 Need help? Call 2-1-1 or

Case number: 1018149697 1-877-541-7905
Fax: 1-877-447-2839
Mail: TEXAS HEALTH AND HUMAN SERVICES
COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

If you are deaf, hard of hearing, or speech

impaired, call 7-1-1 or 1-800-735-2989.
All numbers are free to call.

MS. MARIA BAUTISTA

4110 PARK ST
GREENVILLE TX 75401-4915

Note to Ms. Maria Bautista :

This form is for your employer. They need to fill out the form and return it by 12/04/2023 . You must agree to let them give facts about you.
Fill out and sign this agreement:

I, (print your name) Ms. Maria Bautista allow HHSC to give my Social Security number (SSN) to the employer listed on this form.
My SSN can be used to get facts about my employment. I also allow the employer listed on this form to give facts asked on this form to HHSC.

11/24/2023
Sign here Date

Employer -- your help is needed:

We need proof that the following person is or was your employee.

Employee or former employee Social Security number

Ms. Maria Bautista
644-20-3537
Some employers might get tax refunds or tax credits for hiring people who get certain state benefits.
To learn more, go to TexasWorkforce.org/wotc or email the Texas Workforce Commission at wotc@twc.state.tx.us.

Employer -- please follow these steps:

This person lives in a home in which someone is applying for state benefits. We need to know the amount of money this person makes or made
from this job.

1. Please fill out the “Proof of Employment” form on the next page.
2. If a question doesn't apply, mark it with "N/A."
Q
3. Return the form by 12/04/2023
To send this back to us, you can either: (a) give it to the employee listed above,
(b) mail it in the pre-paid envelope, or (c) fax it to 1-877-447-2839.

H1028
T-01028-0775703866 03/2021
Page 1
 Texas Health and Human Services Commission
Proof of Employment
To be filled out by the employer Case number : 1018149697
1. Company or employer name: Greenville Independent School District
2. Company or employer address - street, city, state, ZIP:
3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP:
5. Is or was this person your employee? Yes No
If no: Stop here - sign and date the bottom of this form and return it.
If yes: Answer all the questions below. If a question doesn't apply, write "N/A."
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply): Full Time Part time Permanent Temporary
10. Average hours per pay period:
11. Rate of pay: $ per: Hour Day Week Month Job

12. How often paid:

Daily Once a week Every 2 weeks

Twice a month Once a month Other:

13. Does or did this person get overtime pay? Yes - often Yes - rarely No - never
14. FICA or FIT withheld? Yes No
15. Is or was this person on leave without pay? Yes No

If yes: Start date of leave: End date of leave:

16. Does this person have a profit sharing or pension plan? Yes No
If yes: What is the current value? $
17. Does your company offer health insurance? Yes No

If yes: This person is: Not enrolled Enrolled with family members Enrolled for self only
If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months? Yes No

If yes: Explain what will change:

19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts):

Date pay Date Actual Gross pay amount Other pay(include tips, EITC Advance Total Pretax
period ended received hours (before taxes taken out) commissions and bonuses) amount Contributions

20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:

21. Does this person still work for you? Yes No

If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $

Employer - read, sign, and date:

I confirm that this information is true and correct to the best of my knowledge:

Employer -sign here Date Title Phone number H1028

03/2021
T-01028-0775703866 Page 2