CASE NO: 1058277426

TEXAS HEALTH AND HUMAN SERVICES COMMISSION Call: 2-1-1 toll-free (if you can't connect, call
P O BOX 149029 1-877-541-7905)
AUSTIN, TEXAS 78714-9029 Fax: 1-877-447-2839 toll-free.
If you are deaf, hard of hearing, or speech impaired, you
can call any number by calling 7-1-1 or 1-800-735-2989
DATE: 11/05/2024

MR. GERALD CANNON

13215 HARKNESS DR
DALLAS TX 75243-2441

It is time to renew your benefits.

The benefits you need to renew have a check-mark next to them:

SNAP TANF Health Care

You can renew benefits online or by returning the form that came with this letter.
To renew online: Go to YourTexasBenefits.com, log in and click 'Manage'. Find the case that says 'Ready for
renewal' and click 'Details'. Click 'Renew Benefits' to begin.
To renew using the form that came with this letter: Return the form by mail using the pre-paid envelope or by
fax. The fax number is listed above. Don't forget to sign the form.

Due dates:
Send your online renewal form or the form with this letter as soon as you can. If we don't get your renewal in time,
your benefits might end.

Your current SNAP food benefits end 12/2024. It's best to return this form as
SNAP food benefits (EDG 729147316) soon as you can. It must be returned by 12/15/2024 if you want SNAP benefits
01/2025.

Need help filling out the form? Call 2-1-1 (toll free).

Form H1830R/May 2019 Page 1

 You might not get benefits if: (1) We don't get your form by the date listed above, (2) you don't meet program rules, or (3)
you don't give us all of the items we need from you (see below).
Items we need from you: Bring or mail copies of the items that apply to your case.
• Identity (only for new people added to your case): Current driver's license or Department of Public Safety ID card.
If a person has the right to make decisions for you (as an authorized representative), that person also needs to give
proof of identity.
• Bank accounts: Current statement for all accounts.
• Proof of income: Last 4 pay stubs or a statement from your employer, or self-employment records.
• Social Security, Supplemental Security Income (SSI), pension benefits, Veteran benefits, Workers compensation,
and unemployment: Award letter or pay stubs.
• Child support you get: District clerk record or letter from the parent who pays showing how much was paid and
when. Must show the name, address, phone number, signature, and date of the parent who pays.
• Child support you pay: Court papers that show what you must pay for child support. For example: divorce decree,
court order or district clerk record.
• Dependent care expenses: Cancelled checks or receipts or a signed statement from the person you pay.
• Health Insurance (only if: (1) it is new or has changed since you last applied, and (2) you are applying for health
care or TANF): Copy of the front and back of the insurance card or policy.
• Housing costs (only if you are applying for SNAP): Recent checks, check stubs, or statement from the mortgage
bank or landlord. Most recent utility bills showing your name and current address.
• Medical Costs (only if you are applying for SNAP) Proof of costs you have: now and costs you expect to have in the
future. You can send bills, receipts, or statements from health care providers (doctors, hospitals, drug stores, etc.).
• Proof of child related to you (only if you are applying TANF): Legal birth, hospital, or baptismal certification.
• Proof of child lives with you (only if you are applying TANF): A signed statement from your landlord or a non-
relative neighbor that includes his or her name, address, and phone number.
• Child vaccines (only if you are applying TANF): Vaccine records for each child.

Your Rights:
• Get an application when you ask for it and have someone help you fill it out.
• Turn in your application on the same day you get it as long as your name and address can be read and it is signed.
• After you turn in your application, we will tell you within a certain number of days if you can get benefits:
• SNAP- within 30 days;
• Children's Medicaid- by whichever date is later, within 30 days or by the agency review date.
The review date is usually in the middle of the last month of your benefit period;
• CHIP- by whichever date is later, within 30 days or by the agency review date. The review date is usually
in the middle of the 11th month of the child's 12-month benefit period, and
• All other benefits- within 45 days
• Get Medicaid coverage, if approved, for 3 months before you applied.
• Ask for a meeting with your caseworker's supervisor.
• Have a fair hearing if you don't agree with an action HHSC took or didn't take in your SNAP, TANF or Medicaid case.
• Have a case review if you don't agree with an action HHSC took or didn't take in your CHIP case.
• To be treated fairly (not be discriminated against) no matter your race, color, religion, sex, age, national origin,
political beliefs, or disability.

Additional SNAP Food Benefit Rights

In addition to your rights, which are listed on Form 1805, Explanation of SNAP Rights and Responsibilities, you have the
following rights:
• You or your authorized representative may file an application in person or by mail. To receive uninterrupted
benefits, you must complete an interview and provide all required verifications.
• You may apply or reapply for food benefits at your SNAP office or Social Security office, if everyone in your
household receives or is applying for SSI. If you have no one to represent you at your SNAP office, you
may be interviewed at your home or by telephone.

If you believe any of these rights have been denied, you may call the Office of the Ombudsman at 1-877-787-8999.

Form H1830R/May 2019 Page 2

Your Texas Benefits: Renewal Form Case number: 1058277426

How to renew Questions?

You can renew online at
www.YourTexasBenefits.com. Call 2-1-1 or 1-877-541-7905.
If you don't want to renew online, fill out this form: After you pick a language, press 2 to:

1. If you need to correct anything on this form: • Ask questions about this form.
(a) cross it out, and (b) update it.
• Find where to get help filling out this form.
2. Sign and date page 12.
3. Attach the items we need. • Check the status of this form.
Items are listed next to the questions. • Ask questions about benefit programs.
4. Send in this form by fax, mail, or in person:
To learn more about benefits, you also can go to
www.hhsc.state.tx.us and www.CHIPMedicaid.org.
Fax: 1-877-447-2839. If the form is 2-sided fax both sides.
Report waste, fraud, and abuse
Mail: TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149025 If you think anyone is misusing HHSC benefits, call
AUSTIN, TEXAS 78714-9025 1-800-436-6184.

In person: At a benefit office. Call 2-1-1 to find one near you. Medicaid for people age 65 or older and for adults
who have a disability:
All phone and fax numbers on this form are free to call. If you want to apply for Medicaid for the Elderly and
People with Disabilities, call 2-1-1. Ask for a different
You have the right to file this application immediately if it has form.
your name, address, and signature.

First name Middle initial Last name

Gerald Cannon
Home address (street and apartment number) City State ZIP County

13215 Harkness Dallas TX 75243 Dallas

Home phone Cell or daytime phone

(469) 673-1877
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 English 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

Form H-1010-R/
04/2024 T-01010-0819984003
Page 1 of 13
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.
SNAP food benefits TANF cash help for families Health care for: Children
Adult caring for a child
Pregnant women
Healthy Texas Women

People renewing their benefits

Everyone on your benefits case should be listed below.
This person's Is this person still
First name Last name Birth date Hispanic or Latino?
relationship to you living in your home?
Yes No
Mark one or more:
American Indian or Alaska Native
Gerald Cannon 5/7/1973 Yes No Asian
Black or African-American
Native Hawaiian or Pacific Islander
White

List anyone who lives with you, but isn't listed above.
Name Male or This Social Birth date U.S. If not a U.S. citizen, tell us: Is this
(first and female? person's Security citizen person Hispanic or Latino?
last) relationship number Immigrant Date this person applying for
registration entered the benefits?
to you
number United States

Yes No
M Yes Yes
Mark one or more:
F No No American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White

Form H-1010-R/
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Page 2 of 13
 Other facts
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?
Is anyone getting cash help, food, or health-care benefits from another state? Yes No
If yes, who? Which state?

Of the following military forces,

• U.S. Armed Forces • National Guard • Reserves • State Military Forces
Is anyone an active-duty member? Yes No
If yes, who?
Is anyone a veteran, including being discharged or released from military service? Yes No
If yes, who?

Is anyone in the household homeless or have a temporary living situation of 90 days or less? Yes No
If yes, who?

Was anyone in foster care when they were age 18 or older? Yes No
If yes, who? In which state?

Is anyone living in the home: (1) age 18 years or older, and (2) a student? Yes No

Is anyone in your home pregnant?

Yes No
If yes, who?
Is this their first pregnancy?
Due date (mm/dd/yyyy) Number of babies expected

What is the first and last name of the unborn child's father?
First: Last:

Was anyone in your home pregnant during the last 12 months? Yes No
If yes, who was pregnant?
When did the pregnancy end?(mm/dd/yyyy):
Does anyone have a disability? Yes No
If yes, who?

Health insurance
Does anyone have health insurance other than Medicare, Medicaid, or CHIP? Yes No
If yes, who?

Send a copy (front and back) of the insurance card.,

Yes No
Does the health insurance cover family planning services?
If yes, if we file a claim on your health insurance will it cause you physical, emotional, or other harm
from your spouse, parents or other persons? Yes No
If yes, tell us why filing a claim with your health insurance company would cause you harm.

Form H-1010-R/
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 Things you are paying for or own
Does anyone own or is anyone paying for a: car, truck, boat, motorcycle, or other vehicle?
Yes No
If yes, give facts below:
Monthly insurance
Year Make Model Monthly payment Money still owed
payment

$ $ $
$ $ $
$ $ $
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.
Send the most recent statement for all accounts. Yes No

Cash: $ Other: $
Bank accounts: All savings $ All Checking $
Property if you don't live on it: $ Homes if you don't live in them: $

Preferred Method of Contact by Health Plan Providers or Managed Care Organizations

If you get health benefits from us, your health plan provider or managed care organization (MCO) may contact you for the
following.

· Appointment reminders
· Eligibility and Enrollment matters
· Information about your health care matters
· Other important notices

You can choose to receive this contact by phone, text message or email.
Text message and e-mail are not encrypted and may not be secure. The risks include an unauthorized third party
intercepting confidential or private information. If one of these is your preferred method of communication for your health
care, be aware of these risks when sending your personal information by text or email.

Your MCO or health plan provider must take reasonable steps to make sure that your health care information stays private.
By completing the information below, you acknowledge that you understand the risks associated with receiving electronic
communications and consent to HHSC sharing your preferred method of contact with your MCO or health plan provider.
Select your preferred contact method from the list below.

Name:

Language you prefer to be contacted in:

Telephone Number:
By Telephone
(if contacted by cell phone, the call may be auto-dialed or pre-recorded, and your carrier’s
usage rates may apply)

Cell phone number:

By Text message
(Carrier message and data rates may apply)

By e-mail E-mail address:

If you choose to provide this information, you will be responsible for notifying your MCO or health plan provider of
any changes to your contact information.You can opt out of being contacted by telephone, text message, or email
by notifying your MCO or health plan provider.
Form H-1010-R/
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 Money coming into your home
List all money everyone living in your home gets or will get. Include money from jobs 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.

Name of Person, company, Hours How often paid? Amount you Total Pretax How often Date
person or agency paying worked get paid Contributions is it Contributed
getting this the money. If you per week (before taxes Per Pay contributed?
money were working for and Period
yourself, write deductions
"self." are taken out)
no longer working no longer working
every 2 weeks every 2 weeks
daily daily
once a week once a week
once a month once a month
other other

no longer working no longer working

every 2 weeks every 2 weeks
daily daily
once a week once a week
once a month once a month
other other
no longer working no longer working
every 2 weeks every 2 weeks
daily daily
once a week once a week
once a month once a month
other other
no longer working no longer working
every 2 weeks every 2 weeks
daily daily
once a week once a week
once a month once a month
other 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?
Yes No
Rent or home payment $ Natural gas/propane $ Taxes on home $
Phone $ Water or sewer $ Electricity $
Insurance on home $ TV cable $ Other $
Send statements or bills showing your name and address.

Form H-1010-R/
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Page 5 of 13
 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, $
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, $
Send statements or bills showing your name and address.

Other costs
Does anyone in the home pay alimony?
Yes No
If yes, how much do you pay each month? $

Was the divorce or separation agreement executed or last modified on or before Dec. 31, 2018? Yes No

Does anyone in the home pay credit card costs?

Yes No
If yes, how much do you pay each month? $

Does anyone in the home pay other regular monthly costs?

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
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? Yes No
If yes, send bills, receipts, or statements.

Form H-1010-R/
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Page 6 of 13
 Legal Information
Nondiscrimination: Social Security numbers:
This institution is prohibited from discriminating on the basis of race, color, national You only need to give the Social
origin, disability, age, sex and in some cases religion or political beliefs. Security numbers (SSN) for people
who want benefits. Giving or
The U.S. Department of Agriculture also prohibits discrimination based on race, applying for an SSN is voluntary;
color, national origin, sex, religious creed, disability, age, political beliefs or reprisal however, anyone who doesn't
or retaliation for prior civil rights activity in any program or activity conducted or apply for an SSN or doesn't give
funded by USDA. an SSN can't get benefits. If you
don't have an SSN, we can help
Persons with disabilities who require alternative means of communication for you apply for one if you are a U.S.
program information (e.g. Braille, large print, audiotape, American Sign Language, citizen or a legal immigrant. You
etc.), should contact the Agency (State or local) where they applied for benefits. must be a U.S. citizen or a legal
Individuals who are deaf, hard of hearing or have speech disabilities may contact immigrant to get an SSN. You can
USDA through the Federal Relay Service at (800) 877-8339. Additionally, program get benefits for your children if they
information may be made available in languages other than English. have SSNs and you don't. We will
not give SSNs to the
Supplemental Nutrition Assistance Program (SNAP) U.S. Immigration and Citizenship
Services. We will use SSNs to
To file a program complaint of discrimination, complete the USDA Program check the amount of money you
Discrimination Complaint Form, (AD-3027), found online at: get (income), if you can get
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or benefits, and the amount of
write a letter addressed to USDA and provide in the letter all of the information benefits you can get. (7 C.F.R
requested in the form. To request a copy of the complaint form, call (866) 632-9992. 273.6 for food benefits; 45 C.F.R
Submit your completed form or letter to USDA by: 205.52 for TANF; and 42 C.F.R
435.910 for health care.)
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.

For any other information dealing with Supplemental Nutrition Assistance Program
(SNAP) issues, persons should either contact the USDA SNAP Hotline Number at
(800) 221-5689, which is also in Spanish or call the State Information/Hotline
Numbers (click the link for a listing of hotline numbers by State); found online at:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

Medicaid and Temporary Assistance for Needy Families

To file a complaint of discrimination regarding a program receiving Federal financial

assistance through the U.S. Department of Health and Human Services (HHS),
write: HHS Director, Office for Civil Rights, Room 509F, 200 Independence Avenue,
S.W., Washington, D.C. 20201 or call (800) 368-1019 (voice) or (800) 537-7697
(TTY).

This institution is an equal opportunity provider.

You also can file a complaint with the Texas Health and Human Services
Commission, Civil Rights Office. Email HHSCivilRightsOffice@hhsc.state.tx.us, call
1-888-388-6332, fax (512) 438-5885, or write Texas Health and Human Services
Commission, Civil Rights Office, 701 W. 51st St., MC W206, Austin, Texas 78751.

Form H-1010-R/
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Page 7 of 13
 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.

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 Keeping my facts private
Eligibility 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:
• 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 • With phone and utility companies. They will find out
gets from other sources (medical records, employment if my bill amount can be lowered. HHSC will give
records, etc.). them my name, address, and phone number.

SNAP food benefits:

Read this box if you are applying for food benefits.
Telling the truth Facts anyone tells or gives HHSC
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.
• Never trade or sell SNAP benefits, Lone Star • Check if that person can get benefits.
Cards, or other devices that allow people to get • Make sure that person is following benefit program
SNAP.
rules.
Anyone who chooses not to tell the truth might: • Help other agencies check if that person can get
other benefits.
• Not get SNAP for a year or more. • Recover benefits that person wasn't supposed to
• Be fined up to $250,000, jailed up to 20 years, or get.
both. • Share facts about that person with other state and
• Lose income tax refunds. federal agencies (for example, the Texas
• Be charged with other crimes. Workforce Commission, the Social Security
• Have to repay benefits. Administration, and the Internal Revenue Service).
• Never get SNAP again.
Form H-1010-R/
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Page 8 of 13
 If a court of law finds you guilty of using or receiving benefits in • Share facts with law enforcement
a transaction involving the sale of a controlled substance, you officials so they can find people on
will be not be eligible for benefits for two years for the first that person's benefits case (the
offense, and permanently for the second offense. household) who are wanted for
If a court of law finds you guilty of having used or received fleeing the law.
benefits in a transaction involving the sale of firearms, • Share facts with federal, state, and
ammunition or explosives, you will be permanently ineligible to private claims collecting agencies
participate in the program upon the first occasion of such for food benefit overpayment
violation. claims collection action.
If a court of law finds you guilty of having trafficked benefits for • Check that person's facts with
an aggregate amount of $500 or more, you will be permanently computer matching programs and
ineligible to participate in the Program upon the first occasion of credit reporting agencies.
such violation.
(Food Stamp Act of 1977, as amended, 7
An individual found to have made a fraudulent statement or U.S.C. 2011-2036.)
representation with respect to the identity or place of residence
of the individual in order to receive multiple SNAP benefits
simultaneously shall be ineligible to participate in the program
for a period of 10 years.
The same is true if anyone lets someone else use their Lone
Star Card.

Medicaid:
Read this box if you are applying for Medicaid benefits.

Giving out facts about me Medical and child support payments

I agree to let Medicaid health care providers

(doctors, drug stores, hospitals, etc.) give Depending on my benefits case, the Attorney General (the state) might
out any facts about me to HHSC. This will check that I am getting the right amount of child or medical support
allow the providers to be paid by Medicaid. payments and coverage.
• If only my child gets Medicaid, I can decide if I want the state to
If I give false information help get any payments and coverage we should get, but don't get
right now.
If I choose not to tell the truth, I might:
• If my child and I both get Medicaid, I must:
• Be charged with a crime. • 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,
• Have to repay benefits.
but I might not.
The same is true if I let someone else use • Identify who the child's other parent is.
my medical card or Medicaid ID.
• Allow the state to keep any medical support payments.
If I'm afraid to give facts about someone
because it could cause harm (physical
or emotional) to me or my child:

Form H-1010-R/
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Page 9 of 13
 If I get Medicaid, HHSC will keep medical service payments I can get
I can ask to not give facts about that from other sources, such as:
person. I will need to work with HHSC and a
family violence center to get a "Family • My health insurance.
Violence Exemption." • 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:

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 benefits or community supervision.)
end, if the TANF amount anyone got still needs to • Have to repay benefits.
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.
People helping you
Did someone help you fill out this form? Yes No
If yes, tell us about that person:

Name

( ) -
Relationship or organization Phone

Address

Women 15-44 years old who do not qualify for Medicaid or CHIP are automatically tested for Healthy Texas Women
(HTW) eligibility. Check the box below if you want to waive HTW testing.

Name I do not want to be tested for HTW.

Name I do not want to be tested for HTW.
Name I do not want to be tested for HTW.

Form H-1010-R/
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Page 10 of 13
 Authorized Representative
If you want, you can give someone the right to act for you (an authorized representative).
That person can:
• Give and get facts for this application.
• Take any action needed for the application process. This includes appealing an HHSC decision.
• Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
• Take any action needed to get benefits. This includes reporting changes and renewing benefits.

If you give someone the right to act for you, that person agrees to:
• fulfill all your responsibilities related to Medicaid;
• keep information about you private;
• obey state and federal laws about conflict of interest and keeping information private, including:
• laws that protect information on people who apply for or receive Medicaid (42 CFR part 431, subpart F);
• laws about the privacy and safety of personally identifiable information (45 CFR §155.260(f)); and
• laws barring the state from paying anyone other than your provider or you for Medicaid services, except in a few
circumstances (42 CFR §447.10).

You can have only one authorized representative for all your benefits from HHSC. If you want to change your authorized
representative: (1) log in to your account on YourTexasBenefits.com and report a change, or (2) call 2-1-1 (after you pick a
language, press 2). If you're a legally appointed representative for someone on this application, send proof with the application.

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) Yes No

Name of authorized representative

Organization

Address
( ) -
Phone

*** 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: 1-800-252-8683

Form H-1010-R/
04/2024 T-01010-0819984003
Page 11 of 13
 Agency Use Only: Voter Registration Status

Agency registered Client declined Agency transmitted Client to mail Mailed to client Other
Agency staff signature

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

Phone number Date

Form H-1010-R/
04/2024 T-01010-0819984003
Page 12 of 13
 Help you can get without filling out this form
Family Violence Program Alcohol and Drug Abuse
Services in your Area Prevention Program
Are you afraid for your children's or
Do you need help finding your safety? Do you or someone you know want to stop
services? using alcohol or drugs?
You can get help to:
Call 2-1-1 (if you can't connect, call • Getting a ride to a safe You can get help:
1-877-541-7905). place. • Quitting.
After you pick a language, press 1. • Finding shelter, legal help, • Dealing with a crisis.
and a job. • Keeping others from using drugs or
• Getting counseling. 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
Literacy Program Payment Program
Are you looking for work?
Do you want help learning to read or Do you need help paying for your health
You can get help: getting a GED? Do you need help with insurance?
• Applying for a job. job skills? Or learning to speak
• Finding a job. English? Call 1-800-440-0493.

Call 2-1-1 to find a Texas Workforce Call 1-800-441-7323 Or write:

Center. (1-800-441-READ). Texas Health and Human
Services Commission
TMHP-HIPP
PO Box 201120
Austin, Texas 78720-1120

Family Planning Women, Infants and Children Important Information for Former
program (WIC) Military Service Members
Do you need help with family
planning? Are you pregnant or a new mother? Women and men who served in any branch
of the United States Armed Forces,
Men and women can get help with: You can get help: including Army, Navy, Marines, Air Force,
• Birth control supplies. 1. Getting food for you and your Coast Guard, Reserves or National Guard
• Other health care. children. may be eligible for additional benefits and
services. For more information, please visit
Call 2-1-1 to find a clinic. 2. Getting vaccines. the Texas Veterans Portal at
https://veterans.portal.texas.gov.
Women age 15 to 44 who can't get Call 1-800-942-3678.
Medicaid or CHIP might be able to
get services in the Healthy Texas
Women program. A parent or legal
guardian must apply for young
women age 15 to 17. To learn more,
go to HealthyTexasWomen.org or
call 1-866-993-9972.

Form H-1010-R/
04/2024 T-01010-0819984003
Page 13 of 13
This page intentionally left blank
Documents To Send With Your Application
Health Care DOCUMENTS NEEDED TO SHOW PROOF
Temporary Medicaid
(Medicaid, Send the documents that are check marked under the program
Assistance for the
Food CHIP, or (s) for which you are applying. You only need to send
for Needy Elderly and
Stamps Healthy documents that apply to your situation. For example, if you are
Families People with
Texas applying for food stamps, but you do not have a bank account,
(TANF) Disabilities
Women) we do not need bank statements.

Identity - Valid driver's license or Department of Public Safety ID

✓ ✓ ✓ ✓ card. Note: If you have an representative, your representative will
need to provide proof of his or her identity, plus proof of your identity.

✓ ✓ ✓ ✓ Social Security - Social Security card/ statement from the Social

Security Administration for each person

✓ ✓ ✓ Citizenship - U.S. passport, Certificate of Naturalization, U.S. birth

certificate, hospital record of birth or Medicare card.
Qualified Alien/Non-Citizenship Status - Alien registration card,
✓ ✓ ✓ ✓ documentation from the Bureau for Citizenship and Immigration
Services (formerly INS).

✓ ✓ ✓ ✓ Legal Representative - Power of attorney, guardianship order,

court order or similar court documents.

✓ ✓ ✓ ✓ Earnings - Pay stubs , copy of checks , a statement from employer

or self-employment records.
Social Security, Pension, Veterans Administration, Supplemental
✓ ✓ ✓ ✓ Security Income, Workers' Compensation or Unemployment
Benefits - Award letter or pay stubs.

✓ ✓ ✓ ✓ Child Support You Obligations - Divorce decree, court order or

copy of district clerk record.
Child Support Payment - Copy of district clerk record or letter from

✓ ✓ ✓ ✓ parent who pays showing any child support amounts and dates paid,
including the person's name, address, telephone number, signature
and date.
Loans, Gifts, Contributions - Promissory note, loan agreement,
✓ ✓ ✓ ✓ statement from person providing the money that includes the person's
name, address, telephone number, signature and date.

✓ ✓ ✓ ✓ Bank Accounts - Current statements for all accounts.

✓ ✓ ✓ ✓ Stocks, Bonds, Trusts, Annuities - Trust agreement, annuity

contract, stock certificate, bond instrument or current statements.

✓ ✓ ✓ ✓ Real Estate, Oil, Gas, Mineral Rights - Current tax statements,

division orders, deeds or royalty statements.

✓ ✓ ✓ Medical Expenses - Medical bills, receipts or statements from the

provider.
Insurance Policies - Copies of life, burial and health insurance

✓ ✓ ✓ policies; statements from the insurance provider showing the current

value. We may also need your spouse or ex-spouse's job related
health insurance information and policies.
Rent/Mortgage - Copies of checks or check stubs, statement from
✓ ✓ mortgage lender or landlord. Also, if you rent your home, please
provide the name, address and telephone number of your landlord.
Form M5017/03/2021
Page 1
 Health Care DOCUMENTS NEEDED TO SHOW PROOF
Temporary Medicaid
(Medicaid, Send the documents that are check marked under the program
Assistance for the
Food CHIP, or (s) for which you are applying or renewing. You only need to
for Needy Elderly and
Stamps Healthy send documents that apply to your situation. For example, if
Families People with
Texas you are applying or renewing for SNAP, but do not have a bank
(TANF) Disabilities
Women) account, we do not need bank statements.

✓ ✓ Utilities - Your most recent utility bills showing your name and
current address.

Dependent Care Expenses - Copies of check or check stubs

✓ ✓ showing when and how often you pay. Include a signed and dated
statement from the person you pay showing that person's address
and telephone number, as well as when and how often you pay.

Pregnancy - Medical records confirming the pregnancy, or call

✓ ✓ 2-1-1 and request Form H3037, Report of Pregnancy, or ask for

more information about how you can provide proof.

Birth of Children - Legal birth certificate, hospital certificate or

baptismal certificate. We also must have proof that the child lives
✓ with you, such as signed statement from your landlord or a non-
relative neighbor that includes his or her name , address and
telephone number.

Child Immunizations - Provide immunization records or proof of

immunizations for each TANF child under the age of six. If you
✓ believe you are exempt from this requirement because of your
religious or conscientious beliefs, call 2-1-1 for the information we will
need.

We wil contact you if we need more information or if you need to take any action. Form M5017/03/2021
Call 2-1-1 if you have questions. Page 2
Texas Health and Human
Services Commission SNAP Food Benefits: Your Rights and Program Rules

What can I buy with SNAP?

SNAP food benefits are used to buy food and garden seeds. Most grocery stores accept SNAP.
You can't use SNAP to:
• Buy tobacco.
• Buy alcoholic drinks.
• Buy things you can't eat or drink.
• Pay for food bills you already owe.

How will I get my SNAP benefits?

You will get a plastic card called the Lone Star Card. Every month your SNAP amount will be put in your Lone Star Card account.
You will use this card like a credit card at the cash register. To get help with your card, call 1-800-777-7328 (toll-free).

Can I get SNAP?

You might be able to get SNAP if the money you get (income) and the things you own are under a set limit.
Some things you own are not counted, for example:
• Your home
• Personal items
• Life insurance policies

How will I know how much I have in my SNAP account?

We will send you a letter telling you how much you will get each month. You can check your balance by logging into your account
at YourTexasBenefits.com or by calling the Lone Star Card help line at 1-800-777-7328 (toll-free).

How long will I get SNAP?

We will send you a letter telling you how long your benefit period is. Most adults age 18 to 54 who do not have a child in the home
can get SNAP benefits for only 3 months in a 3-year period. The benefit period can be longer if the adult works at least 20 hours a
week or is in an approved work program. Some might not have to work or be in a work program to get benefits, such as those
who have a disability or are pregnant.

How do I apply?
• Online: YourTexasBenefits.com.
• At a benefits office: To find a Texas Health and Human Services Commission (HHSC) benefits office near you, go to
YourTexasBenefits.com or call 2-1-1 (after you pick a language, press 1).
• Paper form (H1010): To get a form, you can either:
• Call 2-1-1 (after you pick a language, press 2);
• Call toll-free 1-877-541-7905 (after you pick a language, press 2); or
• Visit an HHSC benefits office.
Can someone else buy food for me?
You can get a Lone Star Card for another person. That person can use the card to buy food for you. You are responsible for what
that person buys with that card. If a card is lost or stolen, you must call us right away at 1-800-777-7328 (toll-free). We will not
replace any SNAP benefits used before you report the loss or theft of the card.

Your Rights
1. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies,
the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are
prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or
reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Form H1805 Page 1

04/2024
 Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print,
audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service
at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found
online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA
and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-
9992. Submit your completed form or letter to USDA by mail at U.S. Department of Agriculture, Office of the Assistant
Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410, by fax (202) 690-7442 or email
at program.intake@usda.gov.

This institution is an equal opportunity provider.

You also can write to Texas Health and Human Services, Civil Rights Office, 701 W. 51st St., MC W206, Austin, Texas
78751, or call 1-888-388-6332.

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either
contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the
State information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

2. You can give us your application form in person or by mail. Another person can give us the form for you. You don't have to
go to an interview before giving us your form. You can give us the form the same day you get it. We must accept your form
if we can read your name and address, and it has been signed.
If you need help filling out the form or applying, we will help you.
3. You can request a paper or electronic copy of any application you filled out and gave to us, regardless of the original method
of submission by calling 211, visiting your local office, or logging in to your YourTexasBenefits.com account.

4. We must give you benefits within 30 days after you give us your application if you: (a) give us everything on time, and (b) we
find you meet SNAP program limits. Some people with very little money might get benefits the next workday after they apply.
5. You can talk to the office supervisor if: (a) you have questions that your caseworker can't answer, or (b) you disagree with a
decision your caseworker makes.
6. You can file a complaint by calling 2-1-1. If you don't get the help you need there, you can call the HHSC Office of the
Ombudsman at 1-877-787-8999. Both numbers are free to call.
7. If you think any action taken on your case is wrong, you can ask for a hearing to appeal. A hearing is a chance for you to tell
a hearing officer the reasons you think the action is wrong. The hearing officer will decide if the right action was taken.

8. A child who gets SNAP will get free school lunches. The child must: (a) go to a public or private school, and (b) be in grades
pre-school to high school. Contact your child's school if:
• You don't want your child to get free school lunches.
• You think your child should get free school lunches but doesn't.
• You have questions about the free school lunch program.

Form H1805 Page 2

04/2024
Program Rules
1. Anyone who applies for or gets SNAP must tell the truth about their benefits case.
2. It is against the law for anyone to do or try to do any of the following:
• Trade, sell, or steal SNAP benefits or Lone Star Cards.
• Share their Lone Star Card PIN (password).
• Use Lone Star Cards that don't belong to them.
• Sell food they make with items bought with SNAP benefits.
• Buy items in refundable containers with SNAP benefits to get refunds and not use the items.
• Re-sell items bought with SNAP benefits.
3. Most people age 16 to 59 must follow work rules to get SNAP benefits. Work rules mean a person must look for a job or be
in an approved work program. If the person has a job, they can't quit without good cause. A person who doesn't follow the
work rules will be penalized.

If your SNAP case has more than one parent or caretaker with a child (age 17 or younger), you must decide which parent
or caretaker will be listed as the "primary wage earner." If you don't decide who will be the primary wage earner, HHSC will
decide for you. If the primary wage earner doesn't follow the work rules, everyone
on the SNAP case will be penalized. Penalties:
• 1st time: No SNAP benefits for 1 month or longer (until the person follows the rules).
• 2nd time: No SNAP benefits for 3 months or longer (until the person follows the rules).
• 3rd time: No SNAP benefits for 6 months or longer (until the person follows the rules).
4. You must tell us about changes to your case within 10 days of the change. We gave you a list that shows the changes we
need to know about (see Form H1019, Report of Change).
5. If you get more SNAP benefits than you should, you must pay them back.
6. If you move out of the state before using all the benefits in your account, you can use your Lone Star Card at stores
that accept SNAP benefits in other states.
7. These are the penalties for people who break SNAP rules on purpose:
• 1st time: Can't get SNAP for 1 year.
• 2nd time: Can't get SNAP for 2 years.
• 3rd time: Can never get SNAP again.
If a court of law decides you can't get benefits, the court will decide for how long.
8. If you have a felony drug conviction on or after September 1, 2015 and:
● If you don't follow parole or community supervision rules, you might not get SNAP for 2 years.
● If you get another felony drug conviction while you are getting SNAP, you can't ever get SNAP again.

If you have any questions, call 2-1-1.

Form H1805
04/2024 Page 3
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