The Your Texas Benefits form is a renewal application used by individuals seeking to maintain their eligibility for various state assistance programs. This form allows residents to provide necessary information for benefits such as food assistance, cash help, and health care. To ensure you continue receiving the support you need, fill out the form by clicking the button below.
The Your Texas Benefits form, specifically the Renewal Form H-1010R, is an essential document for individuals seeking to renew their benefits in Texas. This form is designed to collect necessary information about the applicant and their household, ensuring that benefits such as SNAP food assistance, TANF cash aid, and health care are continued without interruption. Applicants can renew their benefits online or by contacting the Texas Health and Human Services Commission (HHSC) via phone. For those who prefer a paper process, filling out the form is required. It’s crucial to provide accurate details, correct any mistakes, and attach requested documentation to support the application. The form also includes sections to report household income, expenses, and any relevant changes in circumstances. Additionally, applicants may need to undergo an interview, which can often be conducted over the phone, to facilitate the process. Understanding how to complete this form correctly can significantly impact the timely renewal of benefits, making it vital for applicants to pay close attention to the instructions and requirements outlined within.
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)
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.
Page 1 of 10
T-01010-1234567890
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?
Self
01/01/1988
Jane
03/01/1990
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
the United
benefits?
States
M
N
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?
If yes, who? ___________________________________________________
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Is anyone getting cash help, food, or health-care benefits from another state?
If yes, who? __________________________________ Which state? ______________________
Is anyone living in the homes: (1) age 18 years or older, and (2) a student?
Is anyone in your home pregnant?
If yes, who? _____________________________________________
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?
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.
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.
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:
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.
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: $__________
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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
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 $ _____
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?
If yes, $ _________
Does anyone pay child support payments, medical bills, and health insurance for a child outside
your home?
Does anyone pay for costs for people with disabilities or adults who can't take care of themselves?
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Other costs
Does anyone in the home pay alimony?
If yes, how much do you pay each month? $ _________
Does anyone in the home pay credit card costs?
Does anyone in the home pay other regular monthly costs?
Does another person not on your case help anyone on your case pay for any of the above costs?
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.
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
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
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
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
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
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
People helping you
Did someone help you fill out this form?
If yes, tell us about that person:
(
)
-
Relationship or organization
Phone
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)
Name of authorized representative
( ) - 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?
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
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:
Printed name of witness
Parent, guardian, or power of attorney for the person applying you must give proof of this right:
Phone Number
Page 9 of 10
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
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.
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
Filling out the Your Texas Benefits form is a necessary step for individuals seeking to renew their benefits. Follow these steps carefully to ensure that your application is complete and accurate.
Once you have submitted the form, you can check the status of your application online or by calling the provided numbers. It is essential to keep track of any deadlines to ensure your benefits continue without interruption.
The Your Texas Benefits form is used to apply for and renew benefits such as SNAP food benefits, TANF cash assistance, and healthcare programs in Texas. It collects information about your household, income, and expenses to determine eligibility for these programs.
You can renew your benefits online at www.YourTexasBenefits.com . If you prefer not to renew online, you can fill out the renewal form (Form H-1010R) and submit it by fax, mail, or in person at a benefits office.
If you need to correct any information on the form, simply cross it out and write the updated information next to it. Make sure to sign and date the form before submitting it.
You should attach any required documents listed next to the questions on the form. This may include proof of income, identification, and any other relevant information that supports your application.
You can check the status of your application by calling 2-1-1 or 1-877-541-7905. You may also check online at the Your Texas Benefits website.
If you cannot get to a benefits office due to certain reasons, such as living far away or having a disability, you can indicate this on the form. Interviews can often be conducted over the phone to accommodate your situation.
Yes, if you need help filling out the form, you can call 2-1-1 for assistance. There are also resources available online that can guide you through the process.
If you submit the form late, it may affect your eligibility for benefits. It is important to renew your benefits on time to avoid any gaps in assistance. If you are concerned about a late submission, contact the benefits office for guidance.
Yes, you can apply for benefits for your children if they are U.S. citizens or legal immigrants, even if you are not. You do not need to provide your own citizenship status to get benefits for your children.
If you suspect that someone is misusing benefits, you can report it by calling 1-800-436-6184. It is important to provide accurate information to help address any issues of waste, fraud, or abuse.
Incomplete Information: Many individuals fail to fill out all required fields. Missing information can delay the processing of the application.
Incorrect Signatures: Some people forget to sign and date the form. A missing signature can result in the application being considered invalid.
Failure to Attach Necessary Documents: Applicants often neglect to include required documents. Items such as proof of income or identification are crucial for verification.
Not Updating Information: People sometimes fail to correct outdated information. If circumstances change, such as a new address or income, it must be updated on the form.
Ignoring Language Preferences: Some applicants do not specify their preferred language for communication. This can lead to misunderstandings and delays.
Overlooking Questions: Certain questions may be skipped unintentionally. Each question is designed to gather essential information, so it's important to answer all of them.
Not Checking for Errors: Many individuals submit forms without reviewing them for mistakes. Simple typos or inaccuracies can lead to complications in the benefits process.
When applying for benefits in Texas, you may need to complete several forms and documents in addition to the Your Texas Benefits form. Each of these documents plays a vital role in ensuring that your application is processed efficiently and accurately. Below is a list of common forms that are often required alongside the Your Texas Benefits form.
Completing these forms and providing the necessary documentation can feel overwhelming, but they are essential steps in securing the benefits you and your family may need. Ensuring that all required information is accurate and complete can help facilitate a smoother application process.
The Your Texas Benefits form is similar to the SNAP Application, which is used to apply for food assistance. Both documents require personal information, including household details and income sources. Just like the Your Texas Benefits form, the SNAP Application also emphasizes the importance of reporting any changes in household composition or income, ensuring that applicants provide accurate and up-to-date information to determine eligibility for benefits.
Another comparable document is the TANF Application, which is designed for families seeking temporary financial assistance. Similar to the Your Texas Benefits form, the TANF Application collects details about the household members, their relationships, and income. Both forms aim to assess the financial need of the applicants and require documentation to support claims, such as proof of income and expenses.
The Medicaid Application also shares similarities with the Your Texas Benefits form, as it is used to determine eligibility for health care coverage. Both documents require applicants to provide personal information, including household size and income levels. Additionally, they both ask about any existing health insurance coverage, ensuring that applicants are fully transparent about their health care situation.
The WIC Application, which stands for Women, Infants, and Children, is another document that resembles the Your Texas Benefits form. Both forms focus on providing assistance to families in need, particularly those with young children. They require information about household income and the number of dependents, and both emphasize the importance of submitting accurate information to receive the appropriate benefits.
The Housing Assistance Application also parallels the Your Texas Benefits form in its purpose of providing support to those in need. Both documents require details about the household's financial situation, including income and expenses. They also ask about the number of individuals living in the home, which helps determine eligibility for housing assistance programs.
Lastly, the SSI (Supplemental Security Income) Application is similar to the Your Texas Benefits form, as it is used to assess eligibility for financial assistance based on disability or age. Both forms require comprehensive personal information, including income and resources. They also focus on the applicant's living situation, ensuring that all relevant factors are considered when determining eligibility for benefits.
When filling out the Your Texas Benefits form, it is important to follow specific guidelines to ensure your application is processed smoothly. Here are five things you should and shouldn't do:
Here are some key takeaways for filling out and using the Your Texas Benefits form: