Your Texas Benefits: Getting Started

SNAP Food Benefits Health Care Benefits

(This used to be called Food Stamps.) Medicaid and CHIP
Helps buy food for good health. Some people
Helps with medical bills such as bills for
might get help the next work day.
doctors, hospitals, and medicines.
People who can get benefits are:
• Children age 18 and younger who live
with you.
TANF Cash Help
• Pregnant women.
for Families
• Adults who either: (1) are caring for
TANF: Temporary Assistance for Needy
a child in their home or (2) were in
Families
foster care at age 18 or older.
Helps pay for things like food, clothing,
and housing. Healthy Texas Women
• TANF: Helps families with children
Provides free women's health and family
age 18 and younger pay for basic needs.
planning services for women ages 15-44.
TANF gives monthly cash payments.
• One-Time TANF: Helps families with If you want to apply for Medicaid for the
children age 18 and younger in crisis. Elderly and People with Disabilities, you
Crises include losing a job, not finding need a different form. To get that form,
a job, losing a home, or a medical call 2-1-1 (after you pick a language,
emergency. This help is given only press 2).
once every 12 months.
• One-Time TANF for Relatives:
All phone and fax numbers on this form are
Helps grandparents, aunts, uncles, brothers free to call. If you are deaf, hard of hearing,
or sisters who are 25 or older and caring for or speech impaired, you can call any number
related children who get TANF. The relative by calling 7-1-1 or 1-800-735-2989.
can get $1,000 once in a lifetime.

How to Apply
How to send it: YourTexasBenefits.com
Mail: HHSC, PO Box 149024, On this website you can:
What to do: Austin, TX 78714-9968 • Apply for benefits.
Fax: 1-877-447-2839. If your • Find out if you should
1. Fill out this form. form is 2-sided, fax both sides. apply for benefits.
2. Sign and date pages 1 and 20. In person: At a benefits office. • Report changes.
3. Send “Items we need.” To find one near you, go to • Upload items we need
See pages C and D. YourTexasBenefits.com or call 2-1-1 from you.
(after picking a language, press 1). • Renew benefits.

Don’t send this page with your form. Keep for your records. Page A
Texas Health and Human Services Commission (HHSC)
Questions about this form
or about benefits
• Go to YourTexasBenefits.com. Helpful Tips
or These pictures tell you what
• There are tips in the left
• Call 2-1-1 (if you can’t connect, sections you need to fill out.
side of each page. They
call 1-877-541-7905).
can help you save time.
After you pick a language, press 2 to: For example, if
– Ask questions about this form. • Sign and date pages you see this:
1 and 20.
– Find where to get help filling out this form.
– Check the status of this form. • Send “Items we need.” It means that only people
See pages C and D. applying for SNAP food
– Ask questions about benefit programs.
benefits need to fill out
that section.
Report waste, fraud, and abuse
If you think anyone is misusing HHSC How to file a complaint
benefits, call 1-800-436-6184.
If you have a complaint, first try talking to your benefits advisor
or their supervisor. If you still need help, call 1-877-787-8999.

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 services? Are you afraid for your children’s or
Call 2-1-1 (if you can’t connect, your safety? You can get help: Do you or someone you know
call 1-877-541-7905). • Getting a ride to a safe place. want to stop using alcohol or drugs?
After you pick a language, press 1. You can get help:
• Finding shelter, legal help, • Quitting.
and a job. • Dealing with a crisis.
Texas Workforce Network
• Getting counseling. • Keeping others from using
Are you looking for work? drugs or alcohol.
Call the hotline anytime at
You can get help: Call 1-877-966-3784
1-800-799-7233 (1-800-799-SAFE).
• Applying for a job. (1-877-9-NO DRUG).
• Finding a job. Adult Education and Family Health Insurance Premium
Call 2-1-1 to find a Texas Literacy Program Payment Program (HIPP)
Workforce Center. Do you want help learning to Do you need help paying for
Family Planning read or getting a GED? Do you need your health insurance?
help with job skills? Or learning to Call 1-800-440-0493.
Do you need help with family planning?
speak English? Or write: Texas Health and Human
Men and women can get help with:
Call 1-800-441-7323 Services Commission
• Birth control supplies. TMHP-HIPP, PO Box 201120
• Other health care. (1-800-441-READ).
Austin, Texas 78720-1120
Call 2-1-1 to find a clinic.
Women, Infants Important Information for Former
Women age 15 to 44 who can’t get and Children program (WIC) Military Service Members
Medicaid or CHIP might be able to Are you pregnant or a new mother? Women and men who served in
get services in the Healthy Texas You can get help: any branch of the United States
Women program. A parent or legal Armed Forces, including Army, Navy,
• Getting food for you and Marines, Air Force, Coast Guard,
guardian must apply for young your children. Reserves or National Guard may
women age 15 to 17. To learn more, • Getting vaccines. be eligible for additional benefits
go to HealthyTexasWomen.org or and services. For more information,
call 1-866-993-9972. Call 1-800-942-3678.
please visit the Texas Veterans Portal
at https://veterans.portal.texas.gov.

Don’t send this page with your form. Keep for your records. Page B
 Items we need from anyone on your case
Look below and on the next page for items we might need from you. If you bring or send copies
of these items with your application, it might help us. If you send any items to us, send only copies.
Keep the originals for your records.
We only need items that apply to anyone on your case. For example, if no one has a bank account,
we do not need bank statements.

If you are applying for

Any Benefit Program
bringing or sending copies of items that apply to anyone on your case might help us review it faster.

• Identity (proof of who you are) – Current driver’s • Social Security, Supplemental Security
license or Department of Public Safety ID card. Income (SSI), or pension benefits – Award letter or
If a person has the right to act for you (as your pay stubs.
authorized representative), that person also needs
• Military service – Current Military ID
to give proof of identity.
(Form DD-2), military orders, or separation
• Immigration status – Resident card (I-551), arrival/ papers (Form DD-214).
departure form (I-94). Or papers from the U.S.
Citizenship and Immigration Services. We need • Loans and gifts (includes someone paying
copies of the front and back of these forms. bills for you) – Loan agreements or statement from
the person giving you money or paying your bills.
• Legal representative (a person who has the right Must show that person’s name, address, phone
to act for you on legal issues) – Power of attorney number, and signature.
papers, guardianship order, court order, or similar
court documents. • Residence (proof you live in Texas) – Utility bill,
driver’s license, Texas Department of Public Safety
• Veterans benefits, workers’ compensation, ID, rent receipt, letter from landlord (can’t be
or unemployment – Award letter or pay stubs. a relative).

If you are applying for

SNAP food benefits
bringing or sending copies of items that apply to anyone on your case might help us review it faster.

• Proof of income from your job – Last 2 pay stubs • Dependent care expenses – Receipts, canceled
or paychecks, a statement from your employer, or checks, or a signed statement from the person
self-employment records. you pay. A signed statement must show when and
• Bank accounts – The most current statement how much you pay.
for all accounts. • Child support anyone pays – Court papers that show
what you must pay for child support. For example:
• Medical costs – Bills, receipts, or statements from
divorce decree, court order, or district clerk record.
health-care providers (doctors, hospitals, drug
stores, etc.). These items should show costs you • Child support anyone gets – District clerk record.
have now and costs you expect in the future. Or letter from the parent who pays showing how
much, how often and the date it is usually paid.
• Rent or mortgage costs – Recent checks, check
The letter must have the name, address, phone
stubs, or statement from the mortgage bank or
number, and signature of the parent who pays.
landlord. Renters also need to give the landlord’s
name, address, and phone number.

More on the
To get SNAP, a person must be a U.S. citizen or legal resident. next page

If you need help getting these items, let us know. Don’t send this page with your form. Keep for your records. Page C
 More items we need from you

If you are applying for

TANF Cash Help for Families
bringing or sending copies of items that apply to anyone on your case might help us review it faster.

• Proof of income from your job – Last 2 pay stubs • Proof a child lives with you – A signed statement
or paychecks, a statement from your employer, from your landlord or a non-relative neighbor that
or self-employment records. includes his or her name, address, and phone number.
• Bank accounts – Most current statement for • Child support anyone pays – Court papers that show
all accounts. what you must pay for child support. For example: divorce
decree, court order, or district clerk record.
• Proof a child is related to you – Legal birth,
hospital, or baptismal certificate. • Child support anyone gets – District clerk record.
Or letter from the parent who pays showing how much,
• Citizenship – U.S. passport, Certificate of how often and the date it is usually paid. The letter must
Naturalization, U.S. birth certificate (copies of the have the name, address, phone number, and signature of
front and back), hospital record of birth, or the parent who pays.
Medicare card. If you were born in Texas, we might
be able to look up your birth record. • Health insurance – Copy of the front and back
of the insurance card or policy.
• Child’s vaccines – Vaccine records for each child.

If you are applying for

CHIP or Children’s Medicaid or Healthy Texas Women for ages 15-17
bringing or sending copies of items that apply to anyone on your case might help us review it faster.
• A parent or legal guardian must apply for Healthy • Citizenship – U.S. passport, Certificate of
Texas Women for minors age 15-17. Naturalization, U.S. birth certificate (copies of
• Proof of income from your job – One pay stub or the front and back), hospital record of birth, or
paycheck from the last 60 days, a statement from Medicare card. If you were born in Texas, we might
your employer, or self-employment records. be able to look up your birth record.

• Medicaid and CHIP only - Medical costs – Bills or • Most recent income tax return to verify tax deductions.
statements from health-care providers (doctors, drug • The most recent modification of your divorce decree or
stores, etc.) from the past 3 months. We only need separation agreement if you pay or receive alimony.
these items if you haven’t already paid for these
services.

If you are applying for

Medicaid for a Pregnant Woman or an Adult or Healthy Texas Women
bringing or sending copies of items that apply to anyone on your case might help us review it faster.
• Proof of income from your job – Last 2 pay • Citizenship – U.S. passport, Certificate of
stubs or paychecks, a statement from your Naturalization, U.S. birth certificate (copies of
employer, self-employment records, or last year’s the front and back), hospital record of birth, or
tax return. Medicare card. If you were born in Texas, we might
• Medical costs – Bills or statements from be able to look up your birth record.
health-care providers (doctors, hospitals, drug • Most recent income tax return to verify tax deductions.
stores, etc.) from the past 3 months. We only • The most recent modification of your divorce decree or
need these items if you haven’t already paid separation agreement if you pay or receive alimony.
for these services.

If you need help getting these items, let us know. Don’t send this page with your form. Keep for your records. Page D
Your Texas Benefits: Form Please use dark ink. Please print. If you need more room, add pages.
Fill in the circles ( ) like this

Mark the benefits anyone on your case is applying for: Medicaid or CHIP:
Section A Children
Adult Caring for a Child
Your Facts SNAP Food TANF Cash Help
Adult not Caring for a Child
Benefits for Families Pregnant Women
If you're applying to get Healthy Texas Women
SNAP food benefits, the
first month's amount will
be based on the date we Person 1: contact person or head of household
get pages 1 and 2.

Other benefits also are First name Middle name Last name
based on when we get
pages 1 and 2. - - / /
Social Security number Birth date (month/day/year)
If you return only
pages 1 and 2 Mailing address
now, you still need
to fill out pages 3
to 20 before you City State Zip
can get benefits.
( ) - ( ) -
You have the right to Home phone Cell or daytime phone
file this form
immediately if it has
your name, address,
and signature. Home address County

City State Zip

You might be able to get SNAP food benefits the next work day if you:
• Are migrant or seasonal farm worker,
• Have $100 or less in available cash and bank account and expect to earn less than
Section B $150 this month, or
• Have costs for housing or utilities that are more than your cash, bank accounts and
the income you expect for the month.
Food Benefits Answer them for everyone living in your home.
This section is 1. Is anyone in the home a migrant worker or seasonal farm worker? ................ Yes No
only for people
applying for 2. Does anyone in the home have money in the bank or cash?...... Yes No $
SNAP Amount
food benefits. 3. Does anyone in the home expect to receive money this $
month? (This includes money you get from jobs, child Yes No
support, social security and unemployment).................... Amount

4. Does anyone in the home pay costs for housing and utilities? $
(This includes rent, mortgage, water, gas, electric, sewage,
trash, phone and property tax)..................................... Yes No Amount
Find out how to
I certify under penalty of perjury that the information I have provided on this application is true and complete
return your form: to the best of my knowledge. If it is not, I may be subject to criminal prosecution.
See page 3.

Sign here (or have someone with the right to act for you sign) Date More on page 2
H1010
Application for benefits 04/2024
Texas Health and Human Services Commission Page 1
 Is anyone in your home pregnant?................................................. Yes No
Section C
Pregnant If yes, who? Number of
babies expected
Women Is this your first pregnancy?.......... Yes No

This section is Due date / /

only for people What is the first and last name of the unborn child's father?
applying for
health care
First name Last name
benefits.
Was anyone in your home pregnant during the last 12 months? ..... Yes No

If yes, who?
If yes, when did the pregnancy end? / /
Of the following military forces,
Section D • U.S. Armed Forces • Reserves
• National Guard • State Military Forces
Military Service 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?

1.Most people applying for benefits must be interviewed.

We often interview people on the phone.
Section E It helps to know if any of the reasons below make it hard for you to get to a benefits office:
• You live more than 30 • Your work or training
Interview miles from the closest hours don't allow you to
• You are a victim of
family violence.
Help benefits office.
• You can't get a ride.
get to a benefits office
when it's open.
• You take care of
someone in your home.
• The weather is bad. • You can't travel because
• You are sick. you are age 60 or older,
or you have a disability.

Do any of the reasons above apply to you? .................. Yes No

2. If you come to our office, will you need special help or equipment?..... Yes No

If yes, what do you need?

3. What language do you want to speak during the interview?

4. Will you need an interpreter? We can get one for you for free...... Yes No
If yes, mark the one you need:
Spanish Vietnamese

American Sign Language Other:

Agency Use Only Date received: Screened by:

Expedite? Yes No Date screened: Case:

Social Security number: H1010

Application for benefits 04/2024
- - Texas Health and Human Services Commission Page 2
Your Texas Benefits: Form Fill in the circles ( ) like this

Please use dark ink. Please print. If you need more room, add pages.

Section F Person 1: Contact Person or Head of Household

Contacting First name Middle name Last name

You
- - / /
Social Security number Birth date (month/day/year)

E-mail

Are you applying for benefits for yourself or a child? ........................ Yes No
If yes, give your facts below:

Section G Person 1
If you get money from
Person 1 Social Security or railroad retirement,
list the number you have: Social Security claim number Railroad retirement number

Married Single Divorced Live in Texas? Yes No

Separated Widowed Plan to stay in Texas? Yes No

Male Female Hispanic or Latino?............... Yes No

Mark the benefits
Person 1 is applying for: Optional
SNAP Food Benefits Questions Mark one or more: American Indian or Alaska Native Asian
TANF Cash Help Black or African-American Native Hawaiian or Pacific Islander White
for Families:
TANF
One-Time TANF
Are you going to school?.... Yes No If yes, are you going full-time? ..... Yes No
One-Time TANF
for Relatives Are you a U.S. citizen? If no, give facts below. ...................................... Yes No

Medicaid or CHIP for: Are you a refugee or legally admitted immigrant? ....................................... Yes No
Children
Adult caring for a child / /
Adult not caring for a
child
If you have a sponsor, write your sponsor's name Date you entered the U.S. (month/day/year)
Pregnant women
Healthy Texas Women Are you registered with the U.S.
Citizenship and Immigration Services? Yes No
Immigrant registration number

Return this completed form by fax, mail, or in person: If you are applying for Medicaid, CHIP, or
Fax: 1-877-447-2839 Healthy Texas Women:
Mail: HHSC, PO Box 149024, You also must fill out the attached form titled
Austin, TX 78714-9968 "Applying for or renewing Medicaid, CHIP, or
In person: Call 2-1-1 to find an HHSC benefits office near you. Healthy Texas Women"

H1010
Application for benefits 04/2024
Texas Health and Human Services Commission Page 3
 Section H Person 2: adult or child applying, spouse of person applying, or parent living with a child who is a applying

People
First name Middle name Last name
Applying
for Benefits - - / /
Social Security number Birth date (month/day/year)
If this person gets money from
Social Security or railroad
Mark the benefits This person's relationship to you retirement, list the number here: Social Security claim # Railroad retirement #
Person 2 is applying for:
SNAP Food Benefits Married Single Divorced Male Female Hispanic or Latino?
TANF Cash Help Separated Widowed Optional Mark one or more: Black or African-American
for Families:
TANF Live in Texas? Questions
Yes No American Indian or Alaska Native Asian
One-Time TANF
One-Time TANF Plan to stay in Texas? Native Hawaiian or Pacific Islander White
for Relatives
Yes No

Is this person going to school? Yes No If yes, is this person going full-time? Yes No
Medicaid or CHIP for:
Children
Is this person a U.S. citizen? If no, give facts below ................................ Yes No
Adult caring for a child
Adult not caring for a Is this person a refugee or legally admitted immigrant? ................................. Yes No
child
Pregnant women / /
Healthy Texas Women
If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)
Is this person registered with the U.S.
Citizenship and Immigration Services?... Yes No
If you are applying Immigrant registration number
for Medicaid, CHIP,
or Healthy Texas Person 3: adult or child applying, spouse of person applying, or parent living with a child who is a applying
Women:
You also must fill out
the attached form First name Middle name Last name
titled “Applying for
or renewing Medicaid, - - / /
CHIP, or Healthy Social Security number Birth date (month/day/year)
Texas Women?”
If this person gets money from
Social Security or railroad
This person's relationship to you retirement, list the number here: Social Security claim # Railroad retirement #

Mark the benefits Married Single Divorced Male Female Hispanic or Latino?
Person 3 is applying for:
SNAP Food Benefits Separated Widowed Optional Mark one or more: Black or African-American
TANF Cash Help Live in Texas? Questions
Yes No American Indian or Alaska Native Asian
for Families:
TANF Plan to stay in Texas? Native Hawaiian or Pacific Islander White
Yes No
One-Time TANF
One-Time TANF
for Relatives
Is this person going to school? Yes No If yes, is this person going full-time? Yes No
Is this person a U.S. citizen? If no, give facts below ................................ Yes No
Medicaid or CHIP for:
Children Is this person a refugee or legally admitted immigrant? ................................. Yes No
Adult caring for a child
Adult not caring for a / /
child If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)
Pregnant women
Healthy Texas Women Is this person registered with the U.S.
Citizenship and Immigration Services?... Yes No Immigrant registration number
H1010
Application for benefits
04/2024
Texas Health and Human Services Commission Page 4
 Person 4: adult or child applying, spouse of person applying, or parent living with a child who is applying
Section H
People First name Middle name Last name
Applying - - / /
for Benefits Social Security number Birth date (month/day/year)
If this person gets money from
Social Security or railroad
Mark the benefits This person's relationship to you retirement, list the number here: Social Security claim # Railroad retirement #
Person 4 is applying for:
SNAP Food Benefits
Married Single Divorced Male Female Hispanic or Latino?
TANF Cash Help
for Families: Separated Widowed Optional Mark one or more: Black or African-American
TANF Questions
One-Time TANF Live in Texas? Yes No American Indian or Alaska Native Asian
One-Time TANF
for Relatives Plan to stay in Texas? Yes No Native Hawaiian or Pacific Islander White

Medicaid or CHIP for: Is this person going to school? Yes No If yes, is this person going full-time? Yes No
Children
Adult caring for a child Is this person a U.S. citizen? If no, give facts below ................................ Yes No
Adult not caring for a
child Is this person a refugee or legally admitted immigrant? ................................ Yes No
Pregnant women
Healthy Texas Women / /
If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)
If you are applying
for Medicaid, CHIP, Is this person registered with the U.S.
Citizenship and Immigration Services?... Yes No
or Healthy Texas Immigrant registration number
Women:
You also must fill out Person 5: adult or child applying, spouse of person applying, or parent living with a child who is applying
the attached form
titled “Applying for
or renewing Medicaid, First name Middle name Last name
CHIP, or Healthy
Texas Women?" - - / /
Social Security number Birth date (month/day/year)
If this person gets money from
Mark the benefits Social Security or railroad
Person 5 is applying for: This person's relationship to you retirement, list the number here: Social Security claim # Railroad retirement #
SNAP Food Benefits
Married Single Divorced Male Female Hispanic or Latino?
TANF Cash Help
for Families: Separated Widowed Mark one or more:
Optional Black or African-American
TANF
Questions
One-Time TANF Live in Texas? Yes No American Indian or Alaska Native Asian
One-Time TANF
for Relatives Plan to stay in Texas? Yes No Native Hawaiian or Pacific Islander White

Medicaid or CHIP for: Is this person going to school? Yes No If yes, is this person going full-time? Yes No
Children
Adult caring for a child
Adult not caring for a Is this person a U.S. citizen? If no, give facts below ................................ Yes No
child
Pregnant women
Is this person a refugee or legally admitted immigrant? ................................ Yes No
Healthy Texas Women
/ /
If this person has a sponsor, write the sponsor's name. Date person entered the U.S. (month/day/year)
If more than 5
Is this person registered with the U.S.
people are applying Citizenship and Immigration Services?... Yes No
Immigrant registration number
for benefits, add
H1010
more pages with the Application for benefits 04/2024
same facts. Texas Health and Human Services Commission Page 5
 Section I 1st child's name:
More Facts / /
About Children Father's first and last name Father's birth date (mm/dd/yyyy)
Age 18 or - - ( ) -

FATHER
Younger Father's Social Security number Father's phone

This section Father's mailing address City State Zip

is only for
children Father is: In home Out of home Deceased Employer
applying for
TANF.
Mother's first and last name Mother's maiden name
- - / /
MOTHER

Mother's Social Security number Mother's birth date (mm/dd/yyyy)

Time Saving Tip
You only need to give
facts for each father Mother's mailing address City State Zip
and mother one time.
Mother's phone ( ) - Employer
If a child has the same
mother or father as Mother is: In home Out of home Deceased
another child, you can Were these parents ever married to each other? ....................... Yes No
write something like
“same as 1st child”
where the parent's 2nd child's name:
name would go.

/ /
Are you afraid that Father's first and last name Father's birth date (mm/dd/yyyy)
giving facts about the
child's other parent - - ( ) -
FATHER

might put you or your

children in danger? Father's Social Security number Father's phone

You might not have to

help or cooperate with Father's mailing address City State Zip
the Office of Attorney
General to collect child Father is: In home Out of home Deceased Employer
or medical support if you
are afraid. You can ask
not to give these facts by:

• Telling your benefits Mother's first and last name Mother's maiden name
advisor (or designated
representative) reasons
- - / /
MOTHER

why this might put Mother's Social Security number Mother's birth date (mm/dd/yyyy)
you or your children
in danger.

• Signing the Good Mother's mailing address City State Zip

Cause request form.
(Your benefits advisor Mother's phone ( ) - Employer
has this form.)
Mother is: In home Out of home Deceased
Were these parents ever married to each other? ....................... Yes No
H1010
Application for benefits 04/2024
Texas Health and Human Services Commission Page 6
Section I 3rd child's name:

More Facts / /
About Father's first and last name Father's birth date (mm/dd/yyyy)
Children - - ( ) -
Age 18 or
FATHER
Father's Social Security number Father's phone
Younger
(continued)
Father's mailing address City State Zip
Father is: In home Out of home Deceased Employer

Mother's first and last name Mother's maiden name

- - / /
MOTHER

Mother's Social Security number Mother's birth date (mm/dd/yyyy)

Mother's mailing address City State Zip

Mother's phone ( ) - Employer

Mother is: In home Out of home Deceased
Were these parents ever married to each other? ....................... Yes No

4th child's name:

/ /
Father's first and last name Father's birth date (mm/dd/yyyy)
- - ( ) -
FATHER

Father's Social Security number Father's phone

Father's mailing address City State Zip

Father is: In home Out of home Deceased Employer

Mother's first and last name Mother's maiden name

- - / /
If you have more
MOTHER

Mother's Social Security number Mother's birth date (mm/dd/yyyy)

than 4 children
who are age 18
or younger, add Mother's mailing address City State Zip
more pages with
Mother's phone ( ) - Employer
the same facts.
Mother is: In home Out of home Deceased
Were these parents ever married to each other? ....................... Yes No
Application for benefits H1010
04/2024
Texas Health and Human Services Commission Page 7
 Section J Other people in the home
These people live in my home, but they don't want to apply for benefits.
Other People (Parents living with a child age 18 or younger who is applying or a spouse of a person applying should not
in the Home be listed here — they should fill out a box in Section H.)
List the birth date only if the person is your relative.
/ /
Name Relationship to you Birth date (if relative)

/ /
Name Relationship to you Birth date (if relative)

/ /
Name Relationship to you Birth date (if relative)

Other facts
Section K 1. Does anyone have a disability? ............................................................. Yes No

Other facts If yes, who?

2. Is anyone getting cash help, food or health-care
benefits from another state? ............................................................. Yes No

If yes, who? Which state? When did that person last get benefits?
3. Has anyone been convicted of a felony for conduct that:
(1) took place after August 22, 1996, and (2) involved illegal drugs? ....... Yes No
Answer 3, 4, 5,
and 6 only if
anyone is
applying for If yes, who?
TANF cash help
or SNAP food 4. Is anyone living in a place of care such as:
benefits. • A homeless shelter. • A drug treatment center. Yes No
• A shelter for battered women. • A group home. .......................

Homeless? ............ Yes No

If yes, who?
Temporary living situation of 90 days or less? Yes No

5. Was anyone in foster care when they were age 18 or older? .................... Yes No
If yes, who? In which state?
6. When people break program rules, they are sometimes "disqualified" from getting benefits.
People who are disqualified are sent a letter and told they can't get TANF cash help
or SNAP food benefits.
Is anyone living with you disqualified from getting cash help or food
benefits anywhere in the United States? ......................................... Yes No

Social Security number:

Application for benefits
- - Texas Health and Human Services Commission H1010
04/2024
Page 8
 Section L Other health insurance
1. Does anyone get Medicaid, or CHIP? .............................................................. Yes No
Medical
If yes, from which state?
Facts
If yes, date coverage ends (if not ending, write “Not ending”):
This section
is only for 2. Does anyone get health coverage from one the following?............................... Yes No
people
applying for Medicare Employer Insurance TRICARE (don’t check if you
TANF, Medicaid, have direct care or Line of Duty)
CHIP, or Healthy
Peace Corps VA Health-care programs
Texas Women. Other
If yes, give facts below.

Name of insured person (first, middle, last) Insurance company

/ / / /
Policy number Coverage start date Coverage end date

$
Type of coverage Amount you pay each month to cover
your children on this insurance.

Who pays the premium?

Is this COBRA coverage? ..................................................................................... Yes No

Is this a retiree health plan? ................................................................................. Yes No
Is this a limited-benefit plan (like a school accident policy)? ............................. Yes No
Is this a state employee benefit plan? ................................................................... Yes No

Name of insured person (first, middle, last) Insurance company

/ / / /
Policy number Coverage start date Coverage end date

$
Type of coverage Amount you pay each month to cover Who pays the premium?
your children on this insurance.
Is this COBRA coverage? ..................................................................................... Yes No
Is this a retiree health plan? ................................................................................. Yes No
Is this a limited-benefit plan (like a school accident policy)? ............................. Yes No
Is this a state employee benefit plan? ................................................................... Yes No
3. Does the health insurance cover family planning services? ............................. Yes No
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 person? ............ Yes No
If yes: Tell us why filing a claim with your health insurance would cause you harm.

Social Security number:

Application for benefits H1010
- - Texas Health and Human Services Commission 04/2024
Page 9
Section L Medical bills from the past 3 months
Medical If anyone on your case can't pay their medical bills, Medicaid might pay them.
Facts • The bills must be for services they got in the past 3 months.
• You need to show proof of money you get (income) for the months they got services.
(continued)
Does anyone applying for benefits have medical bills for services they got in the past 3
This section months? .................................................................................................................. Yes No
is only for
people
applying for
TANF, Medicaid, If yes, who? (first, middle, last)
or CHIP.

If yes, who? (first, middle, last)

Vehicles
Section M Does anyone own or is anyone paying for a:
• car • truck • boat • motorcycle • other .......................................... Yes No
If yes, give facts below.
Things
Anyone is
Name of owner (first, middle, last) Make / Model Year
Paying for
VEHICLE 1

or Owns
Name of co-owner if also owned by someone outside the home

Skip this section Vehicle is used for a person with a disability. $

if you are Money still owed on vehicle
applying
only for
Medicaid, CHIP,
or Healthy Texas Name of owner (first, middle, last) Make / Model Year
VEHICLE 2

Women.

Name of co-owner if also owned by someone outside the home

Vehicle is used for a person with a disability. $

Money still owed on vehicle

If you need
more room, add
Name of owner (first, middle, last) Make / Model Year
more pages with
VEHICLE 3

the same facts.

Name of co-owner if also owned by someone outside the home

Vehicle is used for a person with a disability. $
Money still owed on vehicle

Social Security number:

Application for benefits
- - Texas Health and Human Services Commission H1010
04/2024
Page 10
Section M Things anyone is paying for or owns
We need to know about items anyone owns or is paying for, such as:
Things • cash • bank accounts • homes and other property • insurance policies • stocks
Anyone is Does anyone own or is anyone paying for these types of items? ........... Yes No
Paying for If yes, give facts below.
or Owns
$
(continued)
Item Account number Value
ITEM 1

Names on account or deeds (include co-owners)

Skip this section
if you are
applying Name and address of bank or business (to contact about the item)
only for
Medicaid, CHIP,
or Healthy Texas
$
Women. Item Account number Value
ITEM 2

If you need Names on account or deeds (include co-owners)

more room, add
more pages.
Name and address of bank or business (to contact about the item)

$
Item Account number Value
ITEM 3

Names on account or deeds (include co-owners)

Name and address of bank or business (to contact about the item)

Section N Money anyone might get from other programs

Is anyone waiting for an answer on an application for one of Yes No
Money the programs listed below? .............................................................
Coming into If yes, mark the program anyone is waiting to hear from.
the Home Social Security (RSDI) Supplemental Security Income (SSI)
Other disability Unemployment compensation benefits

Name of person waiting for an answer Program name

Name of person waiting for an answer Program name

Social Security number:

Application for benefits
- - Texas Health and Human Services Commission
H1010
04/2024
Page 11
 Money from jobs or training
Section N Your job may take money out of your check before taxes. These are pretax contributions.
They may be for retirement savings, medical insurance premiums, health savings accounts,
Money dependent care expenses, commuter expenses or life insurance premiums.
Coming into Did anyone get money in the past 3 months from:
the Home (a) working for someone else (b) training, or (c) working for themself?....... Yes No
If yes, give facts below.
(continued)
$
before taxes and
deductions are taken
Name of person who got money Hours worked Amount paid out

/ / / How often are you paid?

daily twice a month
Start date Last payment date (month/year)
once a week once a month
every 2 weeks other:
Is this person currently working at this job or in training?............................. Yes No
JOB 1

Was this person working for themselves? .................................................... Yes No

If no, list the person or place that paid the money.

Total pretax contributions per pay period: How often is it contributed? Date Contributed

$ before taxes and

deductions are taken
Name of person who got money Hours worked Amount paid
out

/ / / How often are you paid?

Start date Last payment date (month/year) daily twice a month
once a week once a month
every 2 weeks other:
JOB 2

Is this person currently working at this job or in training?............................. Yes No

Was this person working for themselves? ....................................................
Yes No
If no, list the person or place that paid the money.

Total pretax contributions per pay period: How often is it contributed? Date Contributed

$ before taxes and

deductions are taken
Name of person who got money Hours worked Amount paid out
/ / / How often are you paid?
Start date Last payment date (month/year) daily twice a month
once a week once a month
every 2 weeks other:
JOB 3

Is this person currently working at this job or in training?............................. Yes No

Was this person working for themselves? .................................................... Yes No
If no, list the person or place that paid the money.

Total pretax contributions per pay period: How often is it contributed? Date Contributed

Social Security number: H1010

Application for benefits
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04/2024
Page 12
 Section N Other money
Does anyone get, or expect to get, any of the types of money listed below? ............... Yes No
If yes mark other types of money anyone gets or might get soon.
Money Cash or gifts. Payments after being hurt at Loans paid to anyone
Coming into Supplemental Security work (workers' compensation). on your case.
Income (SSI)
the Home Social Security
Payments after losing a job Payments to help with utilities.
Farming or fishing
(unemployment compensation).
Retirement benefits (after expenses paid)
(continued) Alimony.
Veterans benefits Interest or dividends. Rent or royalty (after expenses paid)
Child support anyone gets Payments from private insurance Other
Pensions
If anyone gets, or expects to get, any of these types of money, give the facts below.

$ /
Type of money (item you marked above) Amount you get paid Last payment date (month/year)
MONEY TYPE 1

How often are you paid?

Name of person getting this money (if child support, list child's name) daily twice a month
once a week once a month
every 2 weeks other:

Person, company, or agency paying the money

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

$ /
Type of money (item you marked above) Amount you get paid Last payment date (month/year)
MONEY TYPE 2

How often are you paid?

Name of person getting this money (if child support, list child's name) daily twice a month
once a week once a month
every 2 weeks other:

Person, company, or agency paying the money

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

$ /
Type of money (item you marked above) Amount you get paid Last payment date (month/year)
MONEY TYPE 3

How often are you paid?

Name of person getting this money (if child support, list child's name) daily twice a month
once a week once a month
every 2 weeks other:

Person, company, or agency paying the money

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

$ /
Type of money (item you marked above) Amount you get paid Last payment date (month/year)
MONEY TYPE 4

How often are you paid?

Name of person getting this money (if child support, list child's name) daily twice a month
once a week once a month
every 2 weeks other:

Person, company, or agency paying the money

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

Social Security number:

Application for benefits H1010
- - Texas Health and Human Services Commission
04/2024
Page 13
Section O
Housing costs
Housing 1. Does anyone pay any of the costs listed below for the home they are living in?
Yes No
Or for a home they plan to return to? ........................................................................
Costs
If yes, mark the costs Rent or home payment $ Natural gas/propane $
This section is they have and list Tax on home $ Phone $
only for people the amount: Water and sewer $ Home insurance $
applying for Electricity $ Other $
SNAP benefits.
2. If you pay rent, what is your landlord’s name and phone number?

Landlord's name Phone

3. Does another person not living in the home help anyone on your
case pay for housing costs? ............................................................................. Yes No

Costs to take care of others Examples:

• Child care costs so someone can work,
Does anyone have costs look for work, go to training, or go to school.
Section P to take care of others? Yes No • Costs for people with disabilities or adults who need
help caring for themselves.
• Child support payments, medical bills, and health
Costs to If yes, give facts below.
insurance you pay for a child living outside the home.
Take Care • Alimony payments.

of Others How often you paid?

daily
Type of cost First name of person who gets care or support once a week

$ / / every 2 weeks
twice a month
COST 1

Who pays the cost? Amount paid Date last paid once a month
other:

For court ordered child support

Person or company that gets the money (name, address, and phone number) list child who gets support
(provide copy of court order)

How often you paid?

daily
Type of cost First name of person who gets care or support once a week

$ / / every 2 weeks
twice a month
COST 2

Who pays the cost? Amount paid Date last paid once a month
other:

For court ordered child support

Person or company that gets the money (name, address, and phone number) list child who gets support
(provide copy of court order)

How often you paid?

daily
Type of cost First name of person who gets care or support once a week
every 2 weeks
$ / / twice a month
COST 3

Who pays the cost? Amount paid once a month

Date last paid
other:

For court ordered child support

list child who gets support
Person or company that gets the money (name, address, and phone number)
(provide copy of court order)

Social Security number: H1010

Application for benefits
- - Texas Health and Human Services Commission
04/2024
Page 14
Section Q Medical costs
Does anyone age 60 or older, or anyone with a disability,
Medical costs pay medical costs? .......................................................................... Yes No
This section is
only for people If yes, mark the type of costs they pay:
applying for
Medicaid, CHIP, Doctor Hospital Medicine Health insurance
Healthy Texas
Women, or
SNAP food
benefits.

People helping you

Did someone help you fill out this form?.................................................................. Yes No
If yes, tell us about that person:
Section R
Name
People
Helping ( ) -
You Relationship or organization Phone

Address

Social Security number: H1010

Application for benefits
- - Texas Health and Human Services Commission
04/2024
Page 15
Section S Preferred Method of Contact by Health Plan Providers
or Managed Care Organizations
Preferred
Method of If you get health benefits from us, your health plan provider or managed care organization
(MCO) may contact you for the following.
Contact
• 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.

Social Security number: H1010

Application for benefits
- - Texas Health and Human Services Commission
04/2024
Page 16
Section T Signing up to vote
Applying to register or declining to register to vote will not affect the
Signing Up amount of assistance that you will be provided by this agency.
to Vote If you are not registered to vote where you live now, would
you like to apply to register to vote here today? ............................ Yes No
(optional) 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

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

Section U Person who has the right to act for you

If you want, you can give someone the right to act for you (an authorized representative).
A Person That person can:
Who Can • Give and get facts for this application.
• Take any action needed for the application process. This includes appealing an HHSC decision.
Act for You • Take any action needed to enroll in Medicaid or CHIP. This includes picking a health plan.
• Take any action needed for you 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:
Don't forget • laws that protect information on people who apply for or receive Medicaid
(42 CFR part 431, subpart F);
to sign • laws about the privacy and safety of personally identifiable information (45 CFR §155.260(f)); and
page 20. • 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).

Do you want to give someone the right to act for you -- to be your
authorized representative? ............................................................................ Yes No

If yes, tell us about that person (the authorized representative) by

filling out Appendix C. It is attached to this form.

Social Security number: H1010

Application for benefits
- - Texas Health and Human Services Commission
04/2024
Page 17
Section V Legal information
Your Right to be Treated Fairly Medicaid and Temporary Assistance for
Legal This institution is prohibited from discriminating on the Needy Families
Information basis of race, color, national origin, disability, age, sex
and in some cases religion or political beliefs.
To file a complaint of discrimination regarding a
program receiving Federal financial assistance through
the U.S. Department of Health and Human Services
The U.S. Department of Agriculture also prohibits (HHS), write: HHS Director, Office for Civil Rights,
discrimination based on race, color, national origin, sex, Room 509F, 200 Independence Avenue, S.W.,
religious creed, disability, age, political beliefs or Washington, D.C. 20201 or call (800) 368-1019 (voice)
reprisal or retaliation for prior civil rights activity in any or (800) 537-7697 (TTY).
program or activity conducted or funded by USDA.
This institution is an equal opportunity provider.
Persons with disabilities who require alternative means
of communication for program information (e.g. Braille, You also can file a complaint with the Texas Health and
large print, audiotape, American Sign Language, etc.), Human Services Commission, Civil Rights Office.
should contact the Agency (State or local) where they Email HHSCivilRightsOffice@hhsc.state.tx.us, call
applied for benefits. Individuals who are deaf, hard of 1-888-388-6332, fax (512) 438-5885, or write Texas
hearing or have speech disabilities may contact USDA Health and Human Services Commission, Civil Rights
through the Federal Relay Service at (800) 877-8339. Office, 701 W. 51st St., MC W206, Austin, Texas
Additionally, program information may be made 78751.
available in languages other than English.
Citizenship and Immigration Status
Supplemental Nutrition Assistance You can get benefits for your children who are U.S.
Program (SNAP) citizens or legal immigrants even if you are not a U.S.
To file a program complaint of discrimination, complete citizen or a legal immigrant. You do not have to give
the USDA Program Discrimination Complaint Form, your citizenship or immigration status to get benefits for
(AD-3027), found online at: your children. You only have to give the citizenship or
http://www.ascr.usda.gov/complaint_filing_cust.html, immigration status of people who want benefits. If you
and at any USDA office, or write a letter addressed to are not a U.S. citizen or a legal immigrant, the only
USDA and provide in the letter all of the information benefits you might be able to get are emergency
requested in the form. To request a copy of the Medicaid services. Getting long-term care (Medicaid for
complaint form, call (866) 632-9992. Submit your the Elderly and People with Disabilities) or cash help
completed form or letter to USDA by: (TANF) could affect your immigration status and your
chances of getting a Permanent Resident Card (green
(1) mail: U.S. Department of Agriculture card). Getting other benefits will not affect your
Office of the Assistant Secretary immigration status and your chances of getting a
for Civil Rights Permanent Resident Card. You might want to talk to an
1400 Independence Avenue, SW agency that helps immigrants with legal questions
Washington, D.C. 20250-9410 before you apply. If you are a refugee or have been
given asylum, getting benefits will not affect your
(2) fax: (202) 690-7442; or chances of getting a Permanent Resident Card or
becoming a citizen.
(3) email: program.intake@usda.gov
Social Security Numbers
For any other information dealing with Supplemental You only need to give the Social Security numbers
Nutrition Assistance Program (SNAP) issues, persons (SSNs) for people who want benefits. Giving or
should either contact the applying for an SSN is voluntary; however, anyone who
USDA SNAP Hotline Number at (800) 221-5689, which doesn’t apply for an SSN or doesn’t give an SSN can’t
is also in Spanish or call the State Information/Hotline get benefits. If you don’t have an SSN, we can help you
Numbers (click the link for a listing of hotline numbers by apply for one if you are a U.S. citizen or a legal
State); found online at: immigrant. You must be a U.S. citizen or a legal
http://www.fns.usda.gov/snap/contact_info/hotlines.htm. immigrant to get an SSN. You can get benefits for your
children if they have an SSN and you don’t. We will not
give SSNs to the Bureau of Immigration and Customs
Enforcement. We will use SSNs to check the amount of
money you get (income), if you can get benefits, and
the amount of benefits you can get. (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.)
Social Security number:
Application for benefits H1010
- - Texas Health and Human Services Commission 04/2024
Page 18
 All Benefit Programs SNAP Food Benefits
Section W
Facts HHSC Has About Me Telling the Truth
HHSC uses facts about people applying for benefits to Anyone who applies for or gets SNAP must:
Statement of decide: (1) who can get benefits, and (2) the amount • Tell the truth.
of benefits. HHSC checks facts with the federal • Never trade or sell SNAP benefits, Lone Star Cards, or other
Understanding Income and Eligibility Verification System. If any devices that allow people to get SNAP.
facts don't match, HHSC will check other sources
Read Section W (banks, employers, etc.). If anyone applying for Anyone who chooses
before signing benefits has an immigration registration number,
HHSC must check with the U.S. Citizenship and not to tell the truth might:
page 20.
Immigration Services' (USCIS) system. HHSC • Not get SNAP for a year or more.
will not give anyone's facts to USCIS. • Be fined up to $250,000, jailed up to 20 years, or both.
• Lose income tax refunds.
In most cases, I can see and get facts HHSC has about • Be charged with other crimes.
me. This includes facts I give HHSC and facts HHSC • Have to repay benefits.
gets from other sources (medical records, employment • Never get SNAP again.
records, etc.). I might have to pay to get a copy of these
If a court of law finds you guilty of using or receiving benefits
facts. I can ask HHSC to fix anything that is wrong. I do
in a transaction involving the sale of a controlled substance,
not have to pay to fix a mistake. To ask for a copy or to
you will be not be eligible for benefits for two years for the
fix a mistake, I can call 2-1-1 or my local HHSC benefits
first offense, and permanently for the second offense.
office.
If a court of law finds you guilty of having used or received
Keeping My Facts Private benefits in a transaction involving the sale of firearms,
HHSC will keep my facts private if they were collected: ammunition or explosives, you will be permanently ineligible
• By HHSC staff or contracted provider staff. to participate in the program upon the first occasion of such
• To find out if I can get state benefits. violation.
If a court of law finds you guilty of having trafficked benefits
HHSC can share facts about me: for an aggregate amount of $500 or more, you will be
• When needed for me to get state health-care benefits. permanently ineligible to participate in the Program upon the
• With phone and utility companies. They will find out if first occasion of such violation.
my bill amount can be lowered. HHSC will give them
my name, address, and phone number. An individual found to have made a fraudulent statement or
representation with respect to the identity or place of
residence of the individual in order to receive multiple SNAP
TANF Cash Help for Families benefits simultaneously shall be ineligible to participate in
the program for a period of 10 years.
Child Support or Alimony The same is true if anyone lets someone else use
I agree to: their Lone Star Card.
• Let the state keep any child support or alimony
money owed to anyone during the time they
get TANF.
Facts Anyone Tells or Gives HHSC
• Let the state keep this money after TANF benefits HHSC uses the facts anyone tells or gives HHSC, including Social
end, if the TANF amount anyone got still needs to Security numbers to:
be paid off.
• Tell HHSC about money anyone gets. • Check if that person can get benefits.
• Work with HHSC to get this money; if I don't, I am • Check that person's facts with computer matching programs
breaking the law. and credit reporting agencies.
• Make sure that person is following benefit program rules.
The state will keep only the amount allowed by law. • Help other agencies check if that person can get other
benefits.
• Recover benefits that person wasn't supposed to get.
If I Give False Information • Share facts about that person: (1) with other state and federal
If I choose not to tell the truth, I might: agencies (for example, the Texas Workforce Commission, the
• Be charged with and punished for a crime. Social Security Administration, and the Internal Revenue
(This could include going to prison for up to 10 Service); (2) with law enforcement officials so they can find
years or community supervision.) people on that person's benefits case (the household) who
• Have to repay benefits. are wanted for fleeing the law; and (3) with federal, state, and
• Never get TANF again. private claims collecting agencies for food benefit
overpayment claims collection action.

(Food and Nutrition Act of 2008,

as amended, 7 U.S.C. 2011-2036.)

More on next page

Social Security number:

Application for benefits
- - Texas Health and Human Services Commission
H1010
04/2024
Page 19
 Section X
Medicaid
Statement of If I Give False Information If I don't help the state, my child can get Medicaid,
but I might not.
Understanding If I choose not to tell the truth, I might:
• Be charged with a crime. - Identify who the child's other parent is.
• Have to repay benefits. - Allow the state to keep any medical support
The same is true if I let someone else use my payments.
medical card or Medicaid ID.
• I know I will be asked to cooperate with the
Giving Out Facts About Me agency that collects medical support from an
I agree to let Medicaid health care providers absent parent. If I think that cooperating to collect
(doctors, drug stores, hospitals, etc.) give out medical support will harm me or my children, I can
any facts about me to HHSC. This will allow the tell HHSC and I may not have to cooperate.
Did you...
1. Sign and date providers to be paid by Medicaid.
If I get Medicaid, HHSC will keep medical service
page 1 (if you have payments I can get from other sources, such as:
not already sent it in). Medical and Child Support Payments • My health insurance.
Depending on my benefits case, the Attorney • Money I got because of injuries.
General (the state) might check that I am getting
2. Include the "items • Money collected for me or my children by the
the right amount of child or medical support Office of Attorney General.
we need" listed in payments
the cover section. and coverage. I must tell HHSC about these sources. If I don't, I
• If only my child gets Medicaid, I can decide am breaking the law.
3. Sign and date this if I want the state to help get any payments
page. and coverage we should get, but don't get HHSC will only keep the amount of medical support
right now. and service payments allowed by law. I will work
• If my child and I both get Medicaid, I must: with HHSC to get these funds.
- Help the state get any payments and
coverage we should get, but don't right now.

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) the 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,
Sign here to show your agree: I may be subject to criminal prosecution.

Person applying or their authorized representative

/ /
Sign here Date (mm/dd/yyyy)

Parent, guardian, or power of attorney for the person applying:

( ) - / /
Sign here (you must give proof of this right) Phone Date (mm/dd/yyyy)

Witness (only needed if anyone above signed with an "X" or other mark).

/ /
Sign here Date (mm/dd/yyyy)

Printed name of witness

Ready to send this form to us? See “How to send it” at the bottom of page A.
Social Security number:
Application for benefits
- - Texas Health and Human Services Commission
H1010
04/2024
Page 20
 Applying for or renewing Medicaid, CHIP, or
Healthy Texas Women? If yes, you must fill out this form.
NEED HELP WITH YOUR APPLICATION?
We can help you at no cost to you. Call us at 2-1-1 or 1-877-541-7905 (after you pick a language, press 2).
If you have a hearing or speech disability, call 7-1-1 or any relay service.

Each person listed in Section H of the Your Texas Benefits application needs to answer the questions
Section 1 below (Section 1). The people who should be included in Section H and who should answer the
questions below are:

Your Tax • Yourself. • Anyone you include on your tax

return, even if they don’t live with you.
Return • Your spouse.
• Anyone else age 20 and younger who
• Your children age 20 and younger you take care of and lives with you.
This form needs who live with you.
to be filled out,
(You can still apply for health insurance even if you don’t file a federal income tax return.)
signed, and sent
back with your
application for
benefits.
Person 1: (main contact or head of household)

Are you afraid First name Middle name Last name

that giving us facts
about someone If married, name of spouse:
could cause harm
(physical or
emotional) to you
or your child? Do you plan to file a federal income tax return next year? ............................. Yes No
If yes, answer questions a to c. If no, skip to question c.
If yes, you might
not have to give a. Will you file jointly with a spouse? ................................................... Yes No
us facts about that
person. You might b. Will you claim any dependents on your tax return? ......................... Yes No
be able to get the
“Family Violence If yes, list name(s) of dependents:
Exemption.”

c. Will you be claimed as a dependent on someone's tax return?....... Yes No

If yes, list the name of tax filer: How are you related to the tax filer?

Application for benefits

Texas Health and Human Services Commission More on page 2-A
Addendum A . H1010-M
04/2024
Page 1-A
 Section 1 Person 2:

Your Tax First name Middle name Last name

Return If married, name of spouse:

(continued)
Do you plan to file a federal income tax return next year? ............................. Yes No
If yes, answer questions a to c. If no, skip to question c.

a. Will you file jointly with a spouse? ................................................... Yes No

b. Will you claim any dependents on your tax return? ......................... Yes No
If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?....... Yes No

If yes, list the name of tax filer: How are you related to the tax filer?

Does Person 2 live at the same address as Person 1?................................... Yes No

If no, what is Person 2's address?

Person 3:

First name Middle name Last name

If married, name of spouse:

Do you plan to file a federal income tax return next year? ............................. Yes No
If yes, answer questions a to c. If no, skip to question c.
a. Will you file jointly with a spouse? ................................................... Yes No
b. Will you claim any dependents on your tax return? ......................... Yes No
If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?....... Yes No

If yes, list the name of tax filer: How are you related to the tax filer?

Does Person 3 live at the same address as Person 1?................................... Yes No

If no, what is Person 3's address?

Addendum A . H1010-M
04/2024
Page 2-A
Section 1 Person 4:

Your Tax First name Middle name Last name

Return If married, name of spouse:

(continued) Do you plan to file a federal income tax return next year? ............................. Yes No
If yes, answer questions a to c. If no, skip to question c.
a. Will you file jointly with a spouse? ................................................... Yes No
b. Will you claim any dependents on your tax return? ......................... Yes No
If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?....... Yes No

If yes, list the name of tax filer: How are you related to the tax filer?

Does Person 4 live at the same address as Person 1?................................... Yes No

If no, what is Person 4's address?

Person 5:

First name Middle name Last name

If married, name of spouse:

Do you plan to file a federal income tax return next year? ............................. Yes No
If yes, answer questions a to c. If no, skip to question c.

a. Will you file jointly with a spouse? ................................................... Yes No

b. Will you claim any dependents on your tax return? ......................... Yes No
If yes, list name(s) of dependents:

c. Will you be claimed as a dependent on someone's tax return?....... Yes No

If more than
5 people are If yes, list the name of tax filer: How are you related to the tax filer?
applying for
benefits, add
more pages with Does Person 5 live at the same address as Person 1?................................... Yes No
the same facts.
If no, what is Person 5's address?

Addendum A . H1010-M
04/2024
Page 3-A
 Tax deductions
Section 2
Mark all that apply, give the amount, and how often you pay it.
(You shouldn’t include a cost that you already considered as part of your net self-employment.)
Tax deductions
you claim Alimony paid $ How often?
Was the divorce or separation agreement executed or last modified
Tell us about on or before Dec. 31, 2018? ............................................................. Yes No
things that can Student loan interest $ How often?
be deducted on a
federal income tax Other deductions, such as educator expenses, health savings accounts, moving
return. If anyone expenses for active duty members of the military, tuition and fees $ ___________
has deductions, How often? ____________________ Types ____________________
health coverage
If you have any of these deductions, you will need to send us a copy of your last year’s
costs might
income tax return.
be a little lower.

Section 3 Information about people applying for benefits

1. Does a child applying for health care travel with a family member
who is a migrant farm worker? .................................................................. Yes No
If yes, what is the name of that child or children?
Information
about people
2. Is a child in the Children with Special Health Care Needs program? ........ Yes No
applying for
If yes, who?
benefits
3. Is anyone an American Indian or Native Alaskan? ..................................... Yes No
If yes, you must fill out “Appendix B: American Indian
or Alaska Native Family Member.” It is attached to this form.

4. Does any child on this application have a parent living

outside of the home? ................................................................................... Yes No

5. Healthy Texas Women provides free women’s health and family planning services for
women ages 15-44. To keep your participation in Healthy Texas Women private, you can
get your letters about the program at a different address than what is listed on your
application. Fill out the section below to use a confidential address and phone number:
Mailing Address - Street.
City:
State:
Zip:
Phone number:

6. Women ages 15-44 are automatically tested for Healthy Texas Women (HTW) eligibility if
they do not qualify for Medicaid or CHIP. Check the box below if you 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.
Name ______________________________. I do not want to be tested for HTW.

Addendum A . H1010-M
04/2024
Page 4-A
 Section 4 Money you get
Fill out this section only if the amount of money you get changes or might change from
month to month. If you don’t expect changes to your monthly income, skip this question.

Money you get Your total income this year: Your total income next year (if you think it will be different):

$ $

Section 5 Insurance offered through your job

1. Can anyone listed on this form get health insurance through a job? (Check yes even if the
coverage is from someone else's job, such as a parent or spouse.).......... Yes No
Insurance
If yes, you must fill out “Appendix A: Health coverage from job."
offered
through 2. Did anyone have insurance through a job and lose it
within the past 3 months?...........................................................................
your job Yes No
If yes, who? If yes, end date:

If yes, reason the insurance ended:

Parent’s job ended due to CHIP benefits from another Death of a parent.
layoff or business closing. state ended.
The child has special
Parent’s COBRA or ERS Medicaid benefits from health-care needs.
coverage ended. another state ended. Medicaid benefits ended
Change in parent’s Private health coverage (for any reason).
marital status. ended. Others

A. Is anyone who is applying for health coverage

Section 6 in jail (incarcerated)? ................................................................................. Yes No
If yes, who is in jail?

Read and
B. Renewing your health coverage in future years
sign this To make it easier to find out if I can get help paying for health coverage in future years,
form I agree to allow the agency to use facts about money I get (income data), including
information from tax returns. The agency will send me a notice, let me make any changes,
and I can cancel (opt out) at any time.
I agree: Yes, the agency can get facts listed above and renew my health coverage without asking
me for the next:

5 years (the maximum 3 years Don’t use information from

number of years allowed) tax returns to renew
2 years
4 years my coverage.
1 years

/ /
Sign here Date (mm/dd/yyyy)

Addendum A . H1010-M
04/2024
Page 5-A
 APPENDIX A

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job.
Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions.
You only need to include this page when you send in your application, not the Employer Coverage Tool.

EMPLOYEE Information
1. Employee name (First, Middle, Last) 2. Employee Social Security number

EMPLOYER Information

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

( ) -
7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address
( ) -

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)

13a. If you’re in a waiting or probationary period, when can you enroll in coverage?
List the names of anyone else who is eligible for coverage from this job. (mm/dd/yyyy)

Name: Name: Name:

No (Stop here and go to page 9, Section L)

Tell us about the health plan offered by this employer.

14. Does the employer offer a health plan that meets the minimum value standard*? Yes No

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount
for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly

16. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the
employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly

Date of change (mm/dd/yyyy):

* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

Appendix A . H1010-M
04/2024
Page 6-A
 EMPLOYER COVERAGE TOOL
Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even if it’s
from another person’s job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A.
For example, the answer to question 14 on this page should match question 14 on Appendix A.
Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for
each employer that offers health coverage.

EMPLOYEE Information
The employee needs to fill out this section.
1. Employee name (First, Middle, Last) 2. Social Security number

EMPLOYER Information
Ask the employer for this information.
3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

( ) -
7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address
( ) -

13. Is the employee currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting
or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy)
(Continue)
No (Stop and return this form to employee)

Tell us about the health plan offered by this employer.

Does the employer offer a health plan that covers an employee’s spouse or dependent?
Yes Which people? Spouse Dependent(s)
No
(Go to question 14)

14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15) No (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount
for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form to employee.

16. What change will the employer make for the new plan year?
Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the
employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly

Date of change (mm/dd/yyyy):

* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

Appendix A . H1010-M
04/2024
Page 7-A
 Appendix B
American Indian or Alaska Native Family Member (AI/AN)
Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your application.

Tell us about your American Indian or Alaska Native family member(s).

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian
health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the
following questions to make sure your family gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach.

AI/AN PERSON 1 AI/AN PERSON 2

1. Name First Middle First Middle
(First name, Middle name, Last name)

Last Last

2. Member of a federally recognized tribe?

Yes Yes
If yes, tribe name If yes, tribe name

No No

3. Has this person ever gotten a service from Yes Yes

the Indian Health Service, a tribal health
program, or urban Indian health program, No No
or through a referral from one of these
If no, is this person eligible to get If no, is this person eligible to get
programs?
services from the Indian Health Service, services from the Indian Health Service,
tribal health programs, or urban Indian tribal health programs, or urban Indian
health programs, or through a referral health programs, or through a referral
from one of these programs? from one of these programs?
Yes No Yes No

4. Certain money received may not be counted

for Medicaid or the Children’s Health
Insurance Program (CHIP). List any income $ $
(amount and how often) reported on your
application that includes money from
these sources: How often? How often?

• Per capita payments from a tribe that

come from natural resources, usage
rights, leases, or royalties

• Payments from natural resources,

farming, ranching, fishing, leases,
or royalties from land designated as
Indian trust land by the Department
of Interior (including reservations and
former reservations)

• Money from selling things that have

cultural significance

Appendix B . H1010-M
04/2024
Page 8-A
 APPENDIX C
Assistance with Completing this Application
You can choose an 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 for you 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));
• 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.

1. Name of authorized representative (First name, Middle name, Last name)

2. Address 3. Apartment or suite number

4. City 5. State 6. ZIP code

7. Phone number
( ) -
8. Organization name 9. Organization ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application,
and act for you on all future matters with this agency.
10. Your signature 11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application
for somebody else.

1. Application start date (mm/dd/yyyy)

2. First name, middle name, last name, & suffix

3. Organization name 4. Organization ID number (if applicable)

Appendix C . H1010-M
04/2024
Page 9-A