Your Texas Benefits - Texas Health and Human Services Commission

More documents

Recommendations

Info

Section H People Applying for Benefits Mark the benefits Person 2 is applying for: Food Benefits (SNAP) Cash Help for Families (TANF): TANF One-Time TANF One-Time TANF Grandparent Health Care (Medicaid or CHIP) for: Children Adult Caring for a Child Pregnant Women Mark the benefits Person 3 is applying for: Food Benefits (SNAP) Cash Help for Families (TANF): TANF One-Time TANF One-Time TANF Grandparent Health Care (Medicaid or CHIP) for: Children Adult Caring for a Child Pregnant Women Person 2: spouse, child, or other adult applying for benefits First name | | | | | || | | | | || | | | | | Social Security number This person’s relationship to you Middle name - - || | | | Is this person going to school? | | | | | | || | - | | | | || | - | || | | | | / | / | Birth date (month/day/year) | Last name | / / Is this person a U.S. citizen? If no, give facts below.................................................. Is this person a refugee or legally admitted immigrant? .............................................. | | | Married Single Divorced Separated Widowed Live in Texas? Yes No Optional Questions If this person gets money from Social Security or railroad retirement, list the number here: Social Security claim # Railroad retirement # Male Female Hispanic or Latino?................................................ Yes No Mark one or more: American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Pacific Islander White Yes No If yes, is this person going full-time? Yes / | / | | | | | | | / | / | | | No Yes No Yes No 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 Immigrant registration number Person 3: spouse, child, or other adult applying for benefits First name Middle name Last name Social Security number Birth date (month/day/year) This person’s relationship to you Married Single Divorced Separated Widowed Live in Texas? Yes No Optional Questions If this person gets money from Social Security or railroad retirement, list the number here: Social Security claim # Railroad retirement # Male Female Hispanic or Latino?................................................ Yes No Mark one or more: American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Pacific Islander White 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 Is this person a refugee or legally admitted immigrant? .............................................. Yes No 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 Immigrant registration number H1010 Application for benefits 08/2011 Texas Health and Human Services Commission Page 4
Section H People Applying for Benefits Mark the benefits Person 4 is applying for: Food Benefits (SNAP) Cash Help for Families (TANF): TANF One-Time TANF One-Time TANF Grandparent Health Care (Medicaid or CHIP) for: Children Adult Caring for a Child Pregnant Women Mark the benefits Person 5 is applying for: Food Benefits (SNAP) Cash Help for Families (TANF): TANF One-Time TANF One-Time TANF Grandparent Health Care (Medicaid or CHIP) for: Children Adult Caring for a Child Pregnant Women If more than 5 people are applying for benefits, add more pages with the same facts. Person 4: spouse, child, or other adult applying for benefits First name Middle name Last name | | | | | || | | | | || | | | | | - | - || | / / Social Security number Birth date (month/day/year) This person’s relationship to you Is this person a U.S. citizen? If no, give facts below.................................................. | | | | | || | | | | || - | || | | | | / | / | | | | | | If this person gets money from Social Security or railroad retirement, list the number here: Social Security claim # Railroad retirement # Married Single Divorced Separated Widowed Live in Texas? Yes No Optional Questions Male Female Hispanic or Latino?................................................ Yes No Mark one or more: American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Pacific Islander White Is this person going to school? Yes No If yes, is this person going full-time? Yes No Yes No Is this person a refugee or legally admitted immigrant? .............................................. Yes No | / | / | | | 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 Immigrant registration number Person 5: spouse, child, or other adult applying for benefits First name Middle name Last name - || | Social Security number Birth date (month/day/year) This person’s relationship to you | | | Married Single Divorced Separated Widowed Live in Texas? Yes No Optional Questions If this person gets money from Social Security or railroad retirement, list the number here: Social Security claim # Railroad retirement # Male Female Hispanic or Latino?................................................ Yes No Mark one or more: American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Pacific Islander White 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 Is this person a refugee or legally admitted immigrant? .............................................. Yes No / / | | | 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 Immigrant registration number Application for benefits Texas Health and Human Services Commission No H1010 08/2011 Page 5
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: Your Texas Benefits: Form Section F
Page 11 and 12: Section I More Facts About Children
Page 13 and 14: Section L Other Facts (continued) I
Page 15 and 16: Section N Things Anyone is Paying f
Page 17 and 18: Section O Other money Money Coming
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

Your Texas Benefits - Texas Health and Human Services Commission

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?