Your Texas Benefits - Texas Health and Human Services Commission

Section N
Things
Anyone is
Paying for
or Owns
(continued)
Skip this section
if you are applying
only for Medicaid for
Pregnant Women.
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Section O
Money
Coming into
the Home
Things anyone is paying for or owns
We need to know about items anyone owns or is paying for, such as:
• cash • bank accounts • homes and other property • insurance policies • stocks
Does anyone own or is anyone paying for these types of items? .............................
If yes, give facts below.
Yes No
ITEM 1
ITEM 3 ITEM 2
Item Account number Value
Names on account or deeds (include co-owners)
Name and address of bank or business (to contact about the item)
Item Account number Value
Names on account or deeds (include co-owners)
Name and address of bank or business (to contact about the item)
Item Account number Value
Names on account or deeds (include co-owners)
Name and address of bank or business (to contact about the item)
Money anyone might get from other programs
Is anyone waiting for an answer on an application for one of
the programs listed below? ....................................................................... Yes No
If yes, mark the program anyone is waiting to hear from.
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
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H1010
08/2011
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