Your Texas Benefits - Texas Health and Human Services Commission

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Section O Money Coming into the Home (continued) JOB 1 JOB 2 JOB 3 Money from jobs Did anyone get money in the past 3 months from: (a) working for someone else (b) training, or (c) working for themself?............ Yes No If yes, give facts below. Name of person who got money from a job Hours worked Amount paid / / Start date Last payment date (month/year) / How often are you paid? daily once a week every 2 weeks before taxes and deductions are taken out twice a month once a month other:_______ Is this person currently working at this job?........................................................ Yes No Was this person working for themself? ............................................................... Yes No If no, list the person or place that paid the money. Name of person who got money from a job Hours worked Amount paid / / / How often are you paid? daily Start date Last payment date (month/year) once a week every 2 weeks before taxes and deductions are taken out twice a month once a month other:_______ Is this person currently working at this job?......................................................... Yes No Was this person working for themself? ................................................................ Yes No If no, list the person or place that paid the money. Name of person who got money from a job Hours worked Amount paid / / / How often are you paid? daily Start date Last payment date (month/year) once a week every 2 weeks before taxes and deductions are taken out twice a month once a month other:_______ Is this person currently working at this job?....................................................... Yes No Was this person working for themself? .............................................................. Yes No If no, list the person or place that paid the money. Social Security number: H1010 Application for benefits 08/2011 | | | - | | | - | | | | Texas Health and Human Services Commission Page 12 $ $ $
Section O Other money Money Coming into the Home (continued) MONEY TYPE 1 MONEY TYPE 2 MONEY TYPE 3 MONEY TYPE 4 Does anyone get, or expect to get, any of the types of money listed below? ........ If yes mark other types of money anyone gets or might get soon. Yes No Supplemental Security Income (SSI). Social Security. Cash or gifts. Payments after being hurt at work (workers’ compensation). Loans paid to anyone on your case. Payments from private insurance. Retirement benefits. Payments after losing a job Payments to help with utilities. Veterans benefits. Child support anyone gets. (unemployment compensation). Alimony. Interest or dividends. Rent paid to you. Other ____________________ 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) Name of person getting this money (if child support, list child’s name) Person, company, or agency paying the money $ $ How often are you paid? daily once a week every 2 weeks twice a month once a month other:____________ Type of money (item you marked above) Amount you get paid Last payment date (month/year) How often are you paid? daily Name of person getting this money (if child support, list child’s name) once a week every 2 weeks twice a month Person, company, or agency paying the money once a month other:____________ $ Type of money (item you marked above) Amount you get paid Last payment date (month/year) How often are you paid? daily Name of person getting this money (if child support, list child’s name) once a week every 2 weeks twice a month Person, company, company, or agency paying the money once a month other:____________ $ Type of money (item you marked above) Amount you get paid Last payment date (month/year) How often are you paid? daily Name of person getting this money (if child support, list child’s name) once a week every 2 weeks twice a month Person, company, or agency paying the money once a month other:____________ Social Security number: H1010 | | | - | | | - | | | | Application for benefits 08/2011 Texas Health and Human Services Commission Page 13 / / / /
Page 1 and 2: Your Texas Benefits: Getting Starte
Page 3 and 4: Items we need from anyone on your c
Page 5 and 6: Your Texas Benefits: Form Section A
Page 7 and 8: Your Texas Benefits: Form Section F
Page 9 and 10: Section H People Applying for Benef
Page 11 and 12: Section I More Facts About Children
Page 13 and 14: Section L Other Facts (continued) I
Page 15: Section N Things Anyone is Paying f
Page 19 and 20: Section R Medical Costs This sectio
Page 21 and 22: Section W Statement of Understandin
Page 23 and 24: Texas Health and Human Services Com
Page 25 and 26: Comisión de Salud y Servicios Huma

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