Snap: Social Security Number and Human Services Commission

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  • Topic: Social Security, Social Security number, Social Security Administration
  • Pages : 63 (9205 words )
  • Download(s) : 41
  • Published : February 19, 2013
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Your Texas Benefits: Form
Please use dark ink. Please print. If you need more room, add pages. ) like this Fill in the circles (

Section A

Mark the benefits anyone on your case is applying for:


Your Facts
If you’re applying to get SNAP food benefits, the first month’s amount will be based on the date we get pages 1 and 2. Other benefits also are based on when we get pages 1 and 2.

Food Benefits (SNAP)

Cash Help for Families (TANF)

Health Care (Medicaid or CHIP): Children Adult Caring for a Child Pregnant Woman

Person 1: contact person or head of household
Melissa
First name

A
Middle name

Maldonado
Last name

6

2

9

-

0

7

-

9

6

0

2

0

5

Social Security number

Birth date (month/day/year)

/ 1 6 / 1 9 8 9

419 Endicott, unit 2
If you send only pages 1 and 2 now, you will still need to fill out the rest of the application to get benefits. You have the right to file this form immediately if it has your name, address, and signature. Mailing address

San Antonio
City

Texas
State

78214
ZIP

(210) 834-9843
Home phone 419 Endicott, unit 2 Home address

(210) 834-9843
Cell or daytime phone

Bexar
County

San Antonio
City

Texas
State

78214
ZIP

Section B

You might be able to get SNAP food benefits the next work day based on your answers to these questions. Answer them for everyone living in your home. 1. Is anyone a migrant worker or seasonal farm worker? ......................................... 2. Is the total amount of money that everyone has today $100 or less? (include cash and money in the bank) ............................................................... 3. Do you expect the total amount of money everyone will have this month to be less than $150? ................................................................ 4. Is the amount of your housing bills more than the amount of money (cash and money in the bank) everyone expects to have this month? (Count bills that are paid only by people living in the home. Bills can include rent, mortgage, water, gas, electric, sewage, and phone.) ....... ●

Food Benefits
This section is only for people applying for food benefits.

Yes Yes Yes



No No No



Find out how to return your form: See page 3.

Yes



No

Melissa A Maldonado(E-Signed)
Sign here (or have someone with the right to act for you sign)

01/09/2013
Date

More on page 2
H1010 08/2011

Application for benefits Texas Health and Human Services Commission

Page 1

Section C

Is anyone in your home pregnant? ...........................................................................



Yes

No

Pregnant Women
This section is only for people applying for health-care benefits.

Melissa A Maldonado
If yes, who? Due date

0 7 /

1 0 / 2 0 1 3 Maldonado
Last name

Number of babies expected 1

What is the first and last name of the unborn child’s father?

Miguel
First name

Section D

Is anyone an active duty member of one of these military forces? • U.S. Armed Forces • National Guard • Reserves • State Military Forces

Military Service
This section is only for people applying for health-care benefits.

..........................................................................

Yes



No

If yes, who?

Section E

Interview Help

1. Most people applying for benefits must be interviewed. We often interview people on the phone. 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 miles from the closest benefits office. • You can’t get a ride. • The weather is bad. • You are sick. • Your work or training hours don’t allow you to get to a benefits office when it’s open. • You can’t travel because you are age 60 or older, or you have a disability. • You are a victim of family violence. • You take care of someone in your home.

Do any of the reasons above apply to you?...
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