Your Texas Benefits Form in PDF Modify Your Texas Benefits Here

Your Texas Benefits Form in PDF

The Your Texas Benefits renewal form, identified as Form H-1010R from December 2012, serves as a crucial document for residents of Texas seeking to renew their eligibility for various state benefit programs, including SNAP food benefits, TANF cash help for families, and Medicaid. This form enables applicants to provide necessary updates and maintain their assistance without interruption. For a seamless renewal process, individuals can complete and submit this form online, by mail, or in person, ensuring continuous support for themselves and their families. Don't miss out on the benefits you need; click the button below to start filling out your renewal form today.

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The Your Texas Benefits renewal form, Form H-1010R, updated in December 2012, serves as a critical document for individuals seeking to continue their receipt of state-provided benefits. This comprehensive form is designed to facilitate the renewal process for various assistance programs, including SNAP food benefits, TANF cash assistance for families, health care, and more. For those opting not to renew online, the form provides detailed instructions on how to correct information, the necessity of signing and dating specific pages, attaching required documentation listed next to the respective questions, and the available methods for submission, including fax, mail, or in-person delivery. Additionally, it includes guidance on reporting waste, fraud, and abuse, thereby ensuring the integrity of the benefits system. The form is mindful of applicants' diverse needs by offering assistance in multiple languages, providing information on obtaining help with the form, and addressing potential accessibility challenges for individuals residing far from benefits offices, possessing mobility or travel limitations, or having scheduling conflicts due to work or training hours. It also prompts the applicant to list household members on their benefits case and inquire about circumstances that might affect benefit eligibility such as being charged or convicted of a felony, receiving benefits from another state, or having specific housing, educational, or medical needs. Significantly, the form also outlines the legal information concerning discrimination, the necessity of Social Security numbers for obtaining benefits, and the implications of citizenship and immigration status on eligibility, all of which underline the government's commitment to accessibility and nondiscrimination in the provision of public assistance services.

Your Texas Benefits Sample

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

 

 

TX

 

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

 

SNAP food benefits

 

TANF cash help for families

Health care for:

 

Children

 

 

 

 

 

 

Adult caring for a child who

 

 

 

 

 

 

 

 

 

 

 

 

gets TANF

 

 

 

 

 

 

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

to you

living in your home?

 

 

 

 

 

 

 

 

 

John

Doe

Self

01/01/1988

YES

NO

 

 

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

Birth

U.S.

Immigrant

Date this

 

relationship to

Security

person

 

person entered

 

(first and last)

female?

you

number

date

citizen

registration

applying for

 

 

 

 

 

 

number

the United

benefits?

 

 

 

 

 

 

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? ___________________________________________________

Page 2 of 10

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

 

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: $__________

 

 

 

 

Page 3 of 10

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

 

 

 

 

 

 

 

Name of person

 

 

 

 

 

 

 

paid (before taxes

money. If you were

worked

 

 

 

How often paid?

getting this money

 

 

 

and deductions

working for yourself,

per week

 

 

 

 

 

 

 

 

write “self.”

 

 

 

 

 

 

 

 

are taken out)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

no longer working

 

once a week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

every 2 weeks

 

once a month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

daily

 

other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

no longer working

 

 

once a week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

every 2 weeks

 

 

once a month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

daily

 

 

other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

no longer working

 

 

once a week

 

 

 

 

 

 

 

every 2 weeks

 

 

once a month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

daily

 

 

other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

no longer working

 

 

once a week

 

 

 

 

 

 

 

every 2 weeks

 

 

once a month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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, $ _________

 

 

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.

 

 

 

 

 

Page 4 of 10

T-01010-1234567890

Form H-1010R

 

 

December 2012

 

 

Other costs

 

 

 

 

 

Does anyone in the home pay alimony?

YES

NO

 

If yes, how much do you pay each month? $ _________

 

 

 

 

 

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?

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.

Page 5 of 10

T-01010-1234567890

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

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

 

 

 

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

 

Workforce Commission, the Social Security

 

 

Not get SNAP for a year or more.

 

Administration, and the Internal Revenue

 

Service).

Be fined up to $250,000, jailed up to 20 years,

 

Share facts with law enforcement officials so

or both.

 

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.

 

 

fleeing the law.

Have to repay benefits.

 

Share facts with federal, state, and private

Never get SNAP again.

 

claims collecting agencies for food benefit

 

 

The same is true if anyone lets someone else use their

 

overpayment claims collection action.

Check that person's facts with computer

Lone Star Card.

 

matching programs and credit reporting

 

 

 

 

agencies.

 

(Food Stamp Act of 1977, as amended, 7 U.S.C.

 

2011-2036.)

 

 

 

Page 6 of 10

T-01010-1234567890

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.

 

 

 

Page 7 of 10

T-01010-1234567890

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

NO

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)

YES

NO

Name of authorized representative

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.

Agency Use Only: Voter Registration Status

 

Agency registered

 

Client declined

 

Agency transmitted

 

Client to mail

 

Mailed to client

 

Other

Agency staff signature

Page 8 of 10

T-01010-1234567890

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

Page 9 of 10

T-01010-1234567890

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

 

 

Prevention Program

 

 

 

 

Do you need help finding

Are you afraid for your children's or

 

your safety?

Do you or someone you know want to

services?

 

 

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

 

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

 

 

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

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:

read or getting a GED? Do you

insurance?

 

 

• Applying for a job.

need help with job skills? Or

 

learning to speak English?

Call 1-800-440-0493.

Finding a job.

 

 

Or write:

 

 

 

 

Call 2-1-1 to find a Texas

Call 1-800-441-7323

 

(1-800-441-READ).

Texas Health and Human

Workforce Center.

 

 

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.

 

 

 

 

 

 

 

 

Page 10 of 10

T-01010-1234567890

File Characteristics

Fact Name Description
Renewal Options Renewals for Your Texas Benefits can be completed online at www.YourTexasBenefits.com or by filling out the renewal form (H-1010R) and sending it via fax, mail, or in person.
Required Signatures Signatures are required on pages 9 and 10 of the form when submitting a renewal to ensure accuracy and agreement with the provided information.
Supporting Documents Applicants must attach items listed next to certain questions on the form. These documents are essential for verifying the information provided in the application.
Governing Laws The form adheres to various laws concerning discrimination, privacy of Social Security numbers, and the rights related to citizenship and immigration status, ensuring the fair processing of applications.

Detailed Guide for Writing Your Texas Benefits

Completing the Your Texas Benefits Renewal Form is a critical step for continuing access to various state benefit programs. This form, identified as Form H-1010R (December 2012), is designed to update the Health and Human Services Commission (HHSC) about any changes in your situation that might affect your eligibility for benefits such as SNAP (Supplemental Nutrition Assistance Program), TANF (Temporary Assistance for Needy Families), Medicaid, and others. For those who prefer not to or cannot renew online, the form can be submitted via fax, mail, or in person. To ensure the process is completed correctly and efficiently, follow the steps outlined below.

  1. To correct any information, simply cross out the incorrect information and write the update next to it.
  2. Sign and date the form on pages 9 and 10.
  3. Attach any required items listed next to the questions on the form. These might include proof of income, identification, or evidence of expenses.
  4. Submit the completed form along with any attachments by one of the following methods:
    • Fax: Send to 1-877-447-2839. If the form is printed on both sides, fax both.
    • Mail: Send to HHSC, P.O. Box 14700, Midland, TX 79711-9907.
    • In person: Deliver to a benefits office. Find the nearest one by calling 2-1-1.

After the form is submitted, it will be reviewed by HHSC to determine if your eligibility for benefits remains or has changed based on the information provided. It is also an opportunity for applicants to apply for other benefit programs they might be eligible for but are not currently receiving. Prompt and accurate completion of the form ensures continued support without interruption. For any uncertainties or questions, assistance can be sought by calling 2-1-1 or 1-877-541-7905 where operators can provide guidance in multiple languages.

Common Questions

How can I renew my benefits?

To renew your benefits, you can either do it online at www.YourTexasBenefits.com or by completing the Your Texas Benefits: Renewal Form (Form H-1010R) and submitting it via fax to 1877-447-2839, mailing it to HHSC, P.O. Box 14700, Midland, TX 79711-9907, or in person at a benefit office. To find a benefit office near you, call 2-1-1.

What should I do if I need to correct information on the form?

If you find an error on your form, simply cross out the incorrect information and write the update next to it. Make sure all corrections are clear and legible to avoid processing delays.

Is it necessary to sign the form?

Yes, it is critical that you sign and date pages 9 and 10 of the form. An unsigned form may result in processing delays or a rejection of your renewal application.

What should I attach with the renewal form?

The renewal form requires certain documents for verification. Look for directions next to the questions you’ve answered; these will guide you on what specific items need to be attached. It could range from pay stubs to medical bills, depending on the information you’ve provided.

How can I check the status of my renewal form?

To check the status of your form, you can call 2-1-1 or 1-877-541-7905. After choosing a language, press 2 and follow the prompts to inquire about the status of your renewal form.

What if I also want to apply for Medicaid for the Elderly and People with Disabilities?

If you are looking to apply for Medicaid for the Elderly and People with Disabilities, you will need to ask for a different application form. For assistance and to receive the appropriate form, call 2-1-1 and explain your needs.

Who should be listed on the renewal form?

Everyone currently receiving benefits under your case should be listed on the renewal form. Additionally, if there are other individuals living in your household not receiving benefits but contribute to your household economy, you may need to include information about them as well. Refer to the form instructions for detailed guidance.

Who do I contact if I suspect someone is misusing HHSC benefits?

If you suspect misuse of HHSC benefits by anyone, report it immediately by calling 1-800-436-6184. Your report can help ensure that benefits are used properly by those who truly need them.

Common mistakes

When filling out the Your Texas Benefits form, errors can sometimes occur. Here are some common mistakes to watch out for:

  1. Not correcting information properly. Instead of simply writing over an error, you should cross it out and then update it beside or above the correction.
  2. Forgetting to sign and date the form on the required pages, which are typically near the end. Every form must be signed and dated to be processed.
  3. Omitting necessary attachments. Items required for verification are listed next to specific questions. Make sure these items are included before sending in the form.
  4. Sending the form through only one side if faxing. When faxing, remember to send both sides of each page if the form is printed front and back.
  5. Applying for the wrong type of Medicaid or assistance programs due to a misunderstanding of the eligibility requirements. Specific programs are designed for different groups, such as the elderly or those with disabilities.
  6. Not listing everyone in the household receiving benefits or applying for them. It is crucial to include each person to accurately assess eligibility for benefits.
  7. Overlooking the need to report any cash benefits, food, or healthcare benefits received from another state. This is crucial information that can affect eligibility.
  8. Failing to provide detailed information about income, including self-employment and money received from other sources. Accurate and complete financial information is necessary for determining the level of assistance.

Common oversights also include inaccuracies in:

  • Reporting household members who are not applying for or receiving benefits but still contribute to or affect the household's eligibility.
  • Forgetting to include bank statements or proof of property and other assets.
  • Omitting information about additional expenses, such as childcare, that could potentially increase benefit eligibility.
  • Not utilizing the free interpreter services offered for those who require assistance due to language barriers.

Being thorough and careful when completing the Your Texas Benefits form can prevent delays in receiving assistance and ensure that you get the support you're eligible for.

Documents used along the form

When you're navigating the process of applying for benefits in Texas, filling out the Your Texas Benefits form is just the beginning. To ensure your application is as thorough and accurate as possible, you might need to gather and submit additional forms and documents. Here's a guide to some of the most commonly required documents to accompany your application, aiming to make this journey a bit easier for you.

  • Proof of Income: This document is crucial for verifying the income you reported on your application. It can include recent pay stubs, tax returns, or letters from your employer.
  • Identification: Valid forms of ID for each person applying for benefits, such as driver's licenses, birth certificates, or passports, help verify identities.
  • Social Security Cards: Copies of Social Security cards for each applicant are often required to confirm the social security numbers provided on your application.
  • Proof of Residency: Documents like utility bills, rent receipts, or lease agreements show that you live in Texas and are applying for benefits in the correct state.
  • Citizenship or Immigration Status Documents: For non-U.S. citizens, documents proving legal immigration status or citizenship might be necessary.
  • Medical Expenses: Receipts or statements for medical costs not covered by insurance can be important for those claiming certain health-related benefits or deductions.
  • Childcare Expenses: If you're claiming childcare expenses, providing receipts or contracts from childcare providers is necessary.
  • Child Support Payments: Documentation of child support payments made or received can affect the calculation of your benefits.
  • Bank Statements: Recent bank statements provide insight into your financial situation and help verify assets and income.
  • Disability Documentation: If someone in your household is disabled, documents from a doctor or government agency confirming the disability might be requested.

Each person's situation is unique, so you might not need all these documents, or you may need others not listed here. The key is to provide as complete and accurate a picture of your situation as possible to ensure your benefits application is processed smoothly and efficiently. Remember, accurate documentation helps avoid delays in the approval process, ensuring you receive the assistance you need in a timely manner.

Similar forms

The "Your Texas Benefits" renewal form, used for applying or renewing various state benefits, shares similarities with the Medical Assistance (Medicaid) application form found in many states. Both forms require detailed personal, financial, and health information to determine eligibility for benefits. They typically ask for information on income, household composition, disabilities, if any, and current health insurance coverage. Furthermore, both demand the disclosure of any resources such as bank accounts, properties, or vehicles that could affect the applicant's eligibility.

Similarly, the Supplemental Nutrition Assistance Program (SNAP) application form asks for parallel types of information as the "Your Texas Benefits" form. SNAP forms also require applicants to list all household members, income from all sources, and any accessible resources like cash or savings accounts. The objective is to assess the household's financial situation to determine the amount of assistance they qualify for, ensuring that aid is provided to those most in need.

The Temporary Assistance for Needy Families (TANF) application is another document bearing resemblance to the "Your Texas Benefits" form. This form assesses eligibility for temporary financial assistance for low-income families. It captures detailed information regarding household composition, income, employment status, child care needs, and more. TANF applications often include sections where applicants must list their efforts to find or maintain employment, aligning with the program's goal to encourage self-sufficiency.

The application for the Children's Health Insurance Program (CHIP) also parallels the "Your Texas Benefits" form in several aspects. Similar to Medicaid, it necessitates detailed family and income information to determine children's eligibility for low-cost health insurance. The form includes queries about current health insurance status and offers information on the program's coverage details, underscoring the focus on providing healthcare support to children of low-income families who might not qualify for Medicaid.

Dos and Don'ts

When filling out the Your Texas Benefits form, there are several do's and don'ts that can help ensure your application process is smooth and your chances for receiving benefits are maximized. Understanding and following these guidelines is crucial.

Things you should do:
  • Correctly update any mistakes: If there's a mistake, cross it out neatly and write the correct information next to it. This ensures your form is accurate and can be processed quickly.
  • Sign and date the form: Make sure to sign and date pages 9 and 10 of the form. Your signature is required to process your application.
  • Attach required items: Carefully review the form for any specific items you need to attach for your application and do so accordingly. These could be proofs of income, identity, or other necessary documents.
  • Send the form through the correct channel: Choose whether to fax, mail, or hand-deliver your form. Ensure you use the correct contact information provided on the form for each method.
Things you shouldn't do:
  • Leave sections incomplete: Failing to fill out all relevant sections of the form can lead to delays or denial of benefits. Be thorough and provide all requested information.
  • Provide false information: Honesty is crucial when applying for benefits. Providing incorrect or false information can result in disqualification and potential legal consequences.
  • Forget to check your eligibility for other programs: The form allows you to apply for multiple benefit programs. Make sure to review and check the box next to any other program you wish to apply for, such as SNAP food benefits or Medicaid.
  • Ignore deadlines: Pay attention to submission deadlines and ensure your form is received on time. Late submissions may not be processed.

By following these guidelines, you can help ensure that your application is complete, accurate, and submitted properly, thereby increasing your chances of getting the necessary assistance.

Misconceptions

Many people may have misconceptions about the process and details of completing the Your Texas Benefits Renewal Form. It's important to clarify these misunderstandings to ensure individuals can accurately and confidently navigate their benefits renewal.

  • Online renewal is the only option: While online renewal at www.YourTexasBenefits.com is encouraged for convenience, individuals have the option to renew their benefits by fax, mail, or in person as well. Different methods are provided to accommodate various needs and preferences.

  • Errors on the form require a new form to be completed: If an error is made on the form, it's not necessary to start over with a new form. Instead, one can simply cross out the mistake, write the correct information, and continue. This approach is simpler and less time-consuming.

  • All phone and fax numbers incur charges: All the phone and fax numbers provided on the form for assistance are actually toll-free. This means that individuals seeking help or information will not incur charges when using these contact methods.

  • In-person renewal requires an appointment: Although it might seem that an appointment is necessary for in-person renewal, individuals can actually renew their benefits at any benefit office without necessarily needing an appointment. However, calling ahead to find out the best times to visit or if there are any special instructions can still be beneficial.

  • Only certain programs can be renewed with this form: The form allows for the renewal of a wide range of benefits, including SNAP, TANF, and healthcare programs. It is designed to be a comprehensive tool for individuals needing to renew any combination of their benefits.

  • Interviews are only conducted in person: Interviews for benefits renewal can often be conducted over the phone. This convenience is designed to accommodate individuals who may have difficulty traveling or have scheduling conflicts that make in-person visits challenging.

  • Providing a Social Security Number (SSN) is optional: While the form does state that giving or applying for an SSN is voluntary, it is essential to note that all people who want benefits must provide their SSN. Not providing an SSN may result in the inability to get benefits. The form clarifies that SSNs are necessary to check income and determine benefit eligibility and levels.

  • Applying for benefits will affect immigration status: Applying for most benefits will not affect an individual's immigration status or chances of obtaining a Permanent Resident Card. Exceptions include long-term care through Medicaid for the Elderly and People with Disabilities and TANF cash help, which may have implications. However, emergency Medicaid services and most other benefits will not impact immigration status.

Understanding these points can help clear up any confusion and ensure that individuals feel more prepared and informed when renewing their benefits through the Your Texas Benefits Form. It's always encouraged to seek assistance if any questions or uncertainties arise during the renewal process.

Key takeaways

Filling out the Your Texas Benefits renewal form is essential for maintaining assistance through various state programs. Here are seven key takeaways to help guide you through the process efficiently:

  • Renewal options are flexible; applicants can renew their benefits online at www.YourTexasBenefits.com, or by phone when dialing 2-1-1 or 1-877-541-7905, which also provides additional support for questions about the form or benefits.
  • To correct any information on the form, simply cross out the incorrect information and write the update clearly next to it.
  • It is critical to sign and date pages 9 and 10 of the form to validate the submission.
  • Applicants must attach the required items listed next to specific questions to ensure the application is processed without delay.
  • The completed form can be sent via fax, mail, or delivered in person, providing multiple channels to accommodate different preferences or needs.
  • The form requests detailed information on every individual in the household, including whether they are applying for benefits, to accurately assess eligibility and need.
  • Legal information included at the end of the form underscores the importance of non-discrimination and applicant rights when applying for state benefits, alongside specific instructions regarding Social Security numbers and how they are used in the application process.

Understanding these key aspects of the Your Texas Benefits renewal form can streamline the process, ensuring those who need assistance receive it in a timely manner.

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