Homepage Blank Your Texas Benefits Form
Outline

The Your Texas Benefits form is a crucial document for individuals seeking to renew their benefits in Texas. This form, officially known as Form H-1010R, is designed to streamline the renewal process for various assistance programs, including Medicaid, SNAP food benefits, and TANF cash help. It provides clear instructions on how to renew online or by mail, ensuring that applicants can easily navigate the system. To complete the form, individuals must provide personal information, including their case number, contact details, and details about household members. Additionally, the form requires information about income, expenses, and any other relevant financial data to assess eligibility for benefits. It is essential to attach necessary documentation and sign the form before submission. The process is further supported by resources such as a dedicated helpline and online platforms, which offer assistance in multiple languages. Understanding the requirements and steps outlined in the Your Texas Benefits form is vital for a successful renewal, as it directly impacts access to critical support services.

Sample - Your Texas Benefits Form

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

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Form Information

Fact Name Description
Form Identifier Your Texas Benefits: Renewal Form, Form H-1010R, December 2012
Contact Information For assistance, call 2-1-1 or 1-877-541-7905. You can also visit www.YourTexasBenefits.com.
Submission Methods This form can be submitted by fax, mail, or in person at a benefits office.
Governing Laws Regulations are governed under 7 C.F.R 273.6 for food benefits, 45 C.F.R 205.52 for TANF, and 42 C.F.R 435.910 for health care.

Detailed Guide for Filling Out Your Texas Benefits

Completing the Your Texas Benefits form is an important step in renewing your benefits. Once the form is filled out accurately, it will need to be submitted through one of the available methods. Following the instructions carefully ensures that your application is processed smoothly and efficiently.

  1. Gather necessary documents, such as proof of income, identification, and any other required information.
  2. Begin filling out the form with your personal information, including your first name, middle initial, last name, home address, and contact numbers.
  3. Indicate if you need assistance or an interpreter by answering the relevant questions on the form.
  4. List all individuals living in your household, including their names, relationships to you, and whether they are still living with you.
  5. Provide details regarding any health insurance coverage, assets, and income sources for everyone in your home.
  6. Complete the section regarding housing costs and any other financial obligations, such as child support or medical expenses.
  7. Review the form for any corrections. If changes are needed, cross out the incorrect information and write in the correct details.
  8. Sign and date the required pages, typically pages 9 and 10 of the form.
  9. Attach any necessary documents as specified in the form, ensuring all required information is included.
  10. Submit the completed form via fax, mail, or in person at a designated benefits office. Ensure you keep copies of everything submitted for your records.

Obtain Answers on Your Texas Benefits

  1. What is the Your Texas Benefits form, and who needs to fill it out?

    The Your Texas Benefits form is essential for individuals and families seeking to renew their benefits in Texas. This form is particularly relevant for those applying for programs such as SNAP food benefits, TANF cash assistance, and health care coverage for children and pregnant women. If you are currently receiving these benefits and wish to continue receiving them, you need to complete the renewal form. It’s designed to gather updated information about your household, income, and any changes in your circumstances.

  2. How can I submit the Your Texas Benefits renewal form?

    You have several options for submitting your renewal form. If you prefer a digital approach, you can renew online at www.YourTexasBenefits.com. For those who prefer to speak with someone directly, you can call 2-1-1 or 1-877-541-7905 for assistance. If online submission is not an option for you, you can fill out the form manually and send it in via fax, mail, or in person at a local benefits office. The fax number is 1-877-447-2839, and the mailing address is HHSC, P.O. Box 14700, Midland, TX 79711-9907.

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

    If you find that you need to make corrections on your Your Texas Benefits form, it’s straightforward. Simply cross out the incorrect information and write in the correct details. It’s important to ensure that all information is accurate, as this can affect your eligibility for benefits. After making corrections, don’t forget to sign and date the form before submitting it.

  4. What if I have questions about the benefits programs or need assistance with the form?

    If you have questions regarding the benefits programs or need help filling out the form, you can reach out to the Texas Health and Human Services Commission (HHSC) for guidance. Additionally, the contact numbers provided on the form are free to call. You can also visit www.hhsc.state.tx.us or www.CHIPMedicaid.org for more resources and information. Remember, it’s always better to ask for help if you’re unsure about any part of the process.

Common mistakes

When filling out the Your Texas Benefits form, applicants often make several common mistakes that can lead to delays or denials of their benefits. One frequent error involves incomplete information. Many individuals fail to provide all necessary details about household members, including their names, relationships, and birth dates. Omitting this information can result in the application being returned for correction, thus prolonging the process.

Another mistake is not attaching required documentation. The form specifies that applicants must include certain items, such as proof of income or identification. Failing to include these documents can hinder the evaluation of the application. It is essential for applicants to review the checklist provided on the form to ensure all necessary attachments are included before submission.

Additionally, some applicants neglect to sign and date the form. This oversight may seem minor, but it is critical. Without a signature, the application cannot be processed. Many people mistakenly believe that they can submit the form without this final step, which can lead to significant delays in receiving benefits.

Lastly, misunderstanding the language or instructions on the form can lead to errors. Some individuals may not fully comprehend the questions or may misinterpret what information is required. This can result in inaccurate responses or confusion about eligibility. To avoid this, applicants are encouraged to seek assistance or clarification if they have any doubts about the form's content.

Documents used along the form

The "Your Texas Benefits" form is a crucial document for individuals seeking assistance with various state benefits. Along with this form, several other documents are often required to ensure a smooth application process. Below is a list of forms and documents that may accompany the "Your Texas Benefits" form, each serving a specific purpose in the application for benefits.

  • Application for Benefits (Form H-1010): This initial application form is used to apply for various benefits, including SNAP and TANF. It collects essential information about the applicant and their household.
  • Medicaid Application (Form H-1010-M): This form is specifically for individuals seeking Medicaid coverage. It requires detailed information about income, assets, and household composition.
  • Verification Documents: These may include pay stubs, bank statements, or tax returns. They are essential for verifying income and financial status, which are critical in determining eligibility for benefits.
  • Identity Verification (Form H-1020): This form is used to confirm the identity of applicants. It may require submission of identification documents such as a driver's license or Social Security card.
  • Child Care Verification: If applicable, this document provides proof of child care expenses that the applicant incurs while working or seeking employment, which can impact benefit calculations.
  • Medical Expense Verification: This document outlines any medical expenses incurred by the applicant or household members, which may be considered when calculating benefits.
  • Housing Expense Verification: Rent or mortgage statements are required to confirm housing costs, which are relevant for determining eligibility for assistance programs.
  • Social Security Number Verification (Form H-1020): This form is used to verify the Social Security numbers of all household members applying for benefits.
  • Immigration Status Documentation: For non-citizens, proof of legal residency or immigration status may be necessary to determine eligibility for certain benefits.
  • Renewal Form (Form H-1010R): This is the renewal version of the application for benefits, used to continue receiving assistance after the initial eligibility period expires.

Each of these documents plays a vital role in the benefits application process. Ensuring that all necessary forms are completed and submitted can significantly enhance the likelihood of a successful application. For further assistance, applicants are encouraged to reach out to local benefit offices or helplines.

Similar forms

The Your Texas Benefits form is essential for residents seeking assistance programs in Texas. It shares similarities with several other forms used for benefit applications and renewals. Here are five documents that are comparable to the Your Texas Benefits form:

  • SNAP Application Form: This form is used to apply for the Supplemental Nutrition Assistance Program (SNAP), which provides food assistance. Like the Your Texas Benefits form, it requires personal information, household details, and income verification.
  • TANF Application Form: The Temporary Assistance for Needy Families (TANF) application is designed for families needing cash assistance. It shares a similar structure, asking for information about household members and financial circumstances.
  • Medicaid Application Form: This document is for individuals seeking health coverage through Medicaid. Both forms require detailed information about income, assets, and household composition to determine eligibility.
  • CHIP Application Form: The Children's Health Insurance Program (CHIP) application is aimed at families with children needing health insurance. Like the Your Texas Benefits form, it collects information on family size, income, and residency.
  • Housing Assistance Application: This form is used for individuals seeking help with housing costs. Similar to the Your Texas Benefits form, it asks for personal and financial information to assess eligibility for assistance programs.

Dos and Don'ts

Things to Do When Filling Out the Your Texas Benefits Form:

  • Read the instructions carefully before starting.
  • Fill out all required fields completely and accurately.
  • Attach any necessary documents as specified in the form.
  • Sign and date the form where indicated.
  • Double-check your information for any errors or omissions.
  • Send the form via the method that best suits your needs (fax, mail, or in person).
  • Keep a copy of the completed form for your records.
  • Contact the help line if you have questions or need assistance.

Things to Avoid When Filling Out the Your Texas Benefits Form:

  • Do not leave any required fields blank.
  • Do not use white-out or erase corrections; simply cross out and update.
  • Do not forget to sign and date the form.
  • Do not send the form without the necessary attachments.
  • Do not rush through the form; take your time to ensure accuracy.
  • Do not submit the form without checking the status after sending it.
  • Do not ignore the deadlines for submission.
  • Do not hesitate to ask for help if you are unsure about any part of the form.

Misconceptions

Understanding the Your Texas Benefits form can be challenging. Here are nine common misconceptions about this form, along with clarifications to help you navigate the process more easily.

  1. Online renewal is not an option. Many people believe that they must submit a paper form to renew their benefits. In reality, you can renew online at www.YourTexasBenefits.com.
  2. Corrections cannot be made after submission. Some individuals think they cannot make changes once the form is submitted. However, you can correct mistakes by crossing out the incorrect information and updating it before sending the form.
  3. All applicants must attend an in-person interview. While most applicants are interviewed, many can do so over the phone, especially if they face transportation challenges or other hardships.
  4. Only U.S. citizens can apply for benefits. This is a misconception. Non-citizens can apply for benefits for their children if those children are U.S. citizens or legal immigrants.
  5. Providing a Social Security number is mandatory for all. It is important to note that only individuals applying for benefits need to provide a Social Security number. If you do not have one, assistance is available to help you apply.
  6. Benefits can be denied based solely on immigration status. Many believe that their immigration status will automatically disqualify them from receiving benefits. In fact, only the status of the person applying for benefits is considered; benefits for children do not depend on the parent's status.
  7. All forms of income must be reported. Some applicants think they can omit certain income sources. However, it is essential to report all income, including jobs, unemployment benefits, and any other financial support.
  8. Medicaid will affect immigration status. There is a belief that receiving Medicaid will jeopardize one’s immigration status. In truth, receiving emergency Medicaid services does not impact your chances of obtaining a Permanent Resident Card.
  9. There is no help available for filling out the form. Many individuals think they must complete the form on their own. Assistance is readily available through various resources, including hotlines and local offices.

By addressing these misconceptions, individuals can better understand the Your Texas Benefits form and the resources available to them.

Key takeaways

Here are key takeaways about filling out and using the Your Texas Benefits form:

  • Renewal Options: You can renew your benefits online or by calling 2-1-1 or 1-877-541-7905.
  • Corrections: If you need to correct information on the form, cross it out and update it accordingly.
  • Submission Methods: Submit the completed form via fax, mail, or in person at a benefits office.
  • Required Attachments: Ensure you attach all necessary documents as indicated next to each question on the form.
  • Interviews: Most applicants will need to participate in an interview, often conducted over the phone.
  • Language Assistance: If you need language support, indicate your preferred language or request an interpreter at no cost.
  • Eligibility Questions: Answer all questions about household members accurately, including their relationship to you and their residency status.
  • Income Reporting: List all sources of income for everyone in your household, including employment, benefits, and loans.
  • Medical Costs: Include any medical expenses for household members over 60 or those with disabilities, and provide relevant documentation.
  • Legal Information: Understand that providing Social Security numbers is voluntary, but necessary for benefits eligibility.

Following these guidelines will help ensure your application process goes smoothly and efficiently.