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Click here or scroll down to respond to this candidateApplication for benefitsTexas Health and Human Services CommissionHStreet Address
Street Address /2024Page 1Your Texas Benefits: Form Please use dark ink. Please print. If you need more room, add pages. Fill in the circles like thisMark the benefits anyone on your case is applying for: SNAP Food BenefitsTSAP Food BenefitsTANF Cash Helpfor FamiliesHealth-care benefits:Children Adult caring for a ChildAdult not caring for a ChildPregnant WomanSection AYour FactsIf youre applying toget SNAP foodbenefits, the firstmonths amount willbe based on the date weget pages 1 and 2.Other benefits also arebased on when we getpages 1 and 2.If you send onlypages 1 and 2 now,you will still need tofill out the rest of theapplication to getbenefits.You have the rightto file this formimmediately if it hasyour name, address,and signature.Person 1: contact person or head of householdShinequalFirst name Middle nameJACKSONLast name4 6 1 5 1 3 3 7 5Social Security number- - 1 0 2 8 1 9 7 8Birth date (month/day/year)/ /PO Box 398501Mailing addressDallasCityTexasState75339ZIPPHONE NUMBER AVAILABLEHome phonePHONE NUMBER AVAILABLECell or daytime phone3943 Wilder StHome addressDallasCountyDallasCityTexasState75215ZIPYou might be able to get SNAP food benefits the next work day if you: Are a migrant or seasonal farm worker, Have $100 or less in available cash and bank accounts and expect to earn less than$150 this month, or Have costs for housing or utilities that are more than your cash, bank accounts and the income you expect for the month.Answer them for everyone living in your home.1. Is anyone in the home a migrant worker or a seasonal farm worker? Yes No 2. Does anyone in the home have money in the bank or cash? Yes No Amount 3. Does anyone in the home expect to receive money this month? (This includes money you get from jobs, child support, social security, and unemployment) Yes No Amount 4. Does anyone in the home pay costs for housing and utilities? (This includes rent, mortgage, water, gas, electric, sewage, trash, phone and property tax.) Yes No Amount Section BSNAP FoodBenefitsThis section isonly for peopleapplying forSNAP foodbenefits.Find out how toreturn your form:See page 3.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 (or have someone with the right to act for you sign) Date More on page 24 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 2Is anyone in your home pregnant? Yes No If yes, who?Number ofbabies expectedIs this your first pregnancy? Yes No Due date / / What is the first and last name of the unborn childs father? First name Last nameIf yes, who?Number ofbabies expectedIs this your first pregnancy? Yes No Due date / / What is the first and last name of the unborn childs father? First name Last namePregnantWomenThis section is onlyfor people applyingfor health-carebenefits.Section CWas anyone in your home pregnant during the last 12 months? Yes No If yes, who?When did the pregnancy end?/ /Is anyone an active duty member of one of these military forces? U.S. Armed Forces National Guard Reserves State Military Forces Yes No If yes, who?MilitaryServiceThis section is onlyfor people applyingfor health-carebenefits.Section D4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 31. 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: Do any of the reasons above apply to you? 2. If you come to our office, will you need special help or equipment? 4. Will you need an interpreter? We can get one for you for free. If yes, mark the one you need: You live more than 30miles from the closestbenefits office. You cant get a ride. The weather is bad. You are sick. Your work or traininghours dont allow you toget to a benefits officewhen its open. You cant travel becauseyou are age 60 or older,or you have a disability. You are a victim offamily violence. You take care ofsomeone in your home.InterviewHelpIf yes, what do you need?Yes NoYes NoYes NoSpanish VietnameseAmerican Sign Language Other:Section E3. What language do you want to speak during the interview? English Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 4Your Texas Benefits: FormFill in the circles like thisPlease use dark ink. Please print. If you need more room, add pages. Section FContactingYouPerson 1: Contact Person or Head of HouseholdShinequalFirst name Middle nameJACKSONLast name4 6 1 5 1 3 3 7 5Social Security number1 0 2 8 1 9 7 8Birth date (month/day/year)- - / /EMAIL AVAILABLEE-mailAre you applying for benefits for yourself or a child? Yes No If yes, give your facts below:Section GPerson 1Mark the benefitsPerson 1 is applying for: SNAP Food BenefitsTSAP Food BenefitsTANF Cash Helpfor Families:TANFOne-Time TANFOne-Time TANF for RelativesChildrenHealth-care benefits for:Adult Caring for a ChildAdult not caring for a ChildPregnant WomanPerson 1If you get money from SocialSecurity or railroad retirement,list the number you have: Social Security claim number Railroad retirement number Married Single DivorcedSeparated WidowedLive in Texas? Yes NoPlan to stay in Texas? Yes NoOptionalQuestionsMale Female Hispanic or Latino? Yes No Mark one or more: Black or African-AmericanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianWhiteAre you going to school? Yes No If yes, are you going full-time? Yes No Are you a U.S. citizen? If no, give facts below. Yes No Are you a refugee or legally admitted immigrant? Yes No If you have a sponsor, write your sponsors name Date you entered the U.S. (month/day/year)/ /Are you registered with the U.S.Citizenship and Immigration Services? Yes No Immigrant registration number Women 15-44 years old who do not qualify for Medicaid or CHIP are automatically tested for Healthy Texas Women (HTW) eligibility. Check the box below if you waive HTW testing. I do not want to be tested for HTWVeteran? ... Yes NoReturn this completed formby fax, mail, or in person:Fax: PHONE NUMBER AVAILABLEMail: HHSC, PO Box 149024Austin, TX 78714-9968In person: Call 2-1-1 to find an HHSCbenefits office near you.Use pages 4 and 5 for otherpeople applying for benefits.If you need more pages, you can: Add a blank page and write in your facts.OR Go to www.hhsc.state.tx.us to get anextra page.Click on How to Get Help.Section HPeopleApplyingfor BenefitsApplication for benefitsTexas Health and Human Services CommissionH101004/2024Page 5Hispanic or Latino? Mark one or more:Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money fromSocial Security or railroadretirement, list the number here:adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.Citizenship and Immigration Services? ...QuestionsOptionalPerson 2:UXCYIONFirst name Middle nameTraylorLast nameSocial Security claim # Railroad retirement #Married Single Divorced Live in Texas? Yes NoSeparated Widowed Male Female Yes No Black or African-AmericanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianWhite Yes No Yes NoYes NoYes NoYes No Immigrant registration numberIf this person has a sponsor, write the sponsors name Date you entered the U.S. (month/day/year)/ /Mark the benefitsPerson is applying for:TANF Cash Helpfor Families :Health-care benefits for: SNAP Food BenefitsTSAP Food BenefitsTANFOne-Time TANFOne-Time TANF for RelativesChildrenAdult Caring for a ChildAdult not caring for a ChildPregnant Woman6 2 8 2 3 4 2 1 2Social Security number0 9 1 8 2 0 0 9Birth date (month/day/year)- - / /SonThis person's relationship to youPlan to stay in Texas? Yes NoVeteran? ... Yes No I do not want to be tested for HTW Hispanic or Latino? Mark one or more:Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money fromSocial Security or railroadretirement, list the number here:adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.Citizenship and Immigration Services? ...QuestionsOptionalPerson 3:First name Middle name Last nameSocial Security claim # Railroad retirement #Married Single Divorced Live in Texas? Yes NoSeparated WidowedMale Female Yes NoBlack or African-AmericanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianWhiteYes No Yes NoYes NoYes NoYes No Immigrant registration numberIf this person has a sponsor, write the sponsors name Date you entered the U.S. (month/day/year)/ /Mark the benefitsPerson is applying for:TANF Cash Helpfor Families :Health-care benefits for:SNAP Food BenefitsTSAP Food BenefitsTANFOne-Time TANFOne-Time TANF for RelativesChildrenAdult Caring for a ChildAdult not caring for a ChildPregnant WomanSocial Security number Birth date (month/day/year)- - / /This person's relationship to youPlan to stay in Texas? Yes NoVeteran? ... Yes No I do not want to be tested for HTW Section HPeopleApplyingfor BenefitsApplication for benefitsTexas Health and Human Services CommissionH101004/2024Page 6Hispanic or Latino? Mark one or more:Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money fromSocial Security or railroadretirement, list the number here:adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.Citizenship and Immigration Services? ...QuestionsOptionalPerson 4:First name Middle name Last nameSocial Security claim # Railroad retirement #Married Single Divorced Live in Texas? Yes NoSeparated WidowedMale Female Yes NoBlack or African-AmericanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianWhiteYes No Yes NoYes NoYes NoYes No Immigrant registration numberIf this person has a sponsor, write the sponsors name Date you entered the U.S. (month/day/year)/ /Mark the benefitsPerson is applying for:TANF Cash Helpfor Families :Health-care benefits for:SNAP Food BenefitsTSAP Food BenefitsTANFOne-Time TANFOne-Time TANF for RelativesChildrenAdult Caring for a ChildAdult not caring for a ChildPregnant WomanSocial Security number Birth date (month/day/year)- - / /This person's relationship to youPlan to stay in Texas? Yes NoVeteran? ... Yes No I do not want to be tested for HTW Hispanic or Latino? Mark one or more:Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money fromSocial Security or railroadretirement, list the number here:adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.Citizenship and Immigration Services? ...QuestionsOptionalPerson 5:First name Middle name Last nameSocial Security claim # Railroad retirement #Married Single Divorced Live in Texas? Yes NoSeparated WidowedMale Female Yes NoBlack or African-AmericanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianWhiteYes No Yes NoYes NoYes NoYes No Immigrant registration numberIf this person has a sponsor, write the sponsors name Date you entered the U.S. (month/day/year)/ /Mark the benefitsPerson is applying for:TANF Cash Helpfor Families :Health-care benefits for:SNAP Food BenefitsTSAP Food BenefitsTANFOne-Time TANFOne-Time TANF for RelativesChildrenAdult Caring for a ChildAdult not caring for a ChildPregnant WomanSocial Security number Birth date (month/day/year)- - / /This person's relationship to youPlan to stay in Texas? Yes NoVeteran? ... Yes No I do not want to be tested for HTW Section IMore FactsAbout ChildrenAge 18 orYoungerThis section isonly for childrenapplying for TANFcash help forfamilies.Time Saving TipYou only need to givefacts for each fatherand mother one time.If a child has the samemother or father asanother child, you canwrite something likesame as 1st childwhere the parentsname would go.Are you afraid thatgiving facts about thechilds other parentmight put you or yourchildren in danger?You might not have tohelp or cooperate withthe Office of AttorneyGeneral to collect childor medical support if youare afraid. You can asknot to give these facts by: Telling your benefitsadvisor (or designatedrepresentative) reasonswhy this might putyou or your childrenin danger. Signing the GoodCause request form.(Your benefits advisorhas this form.)Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 71st child's name:Father is:Were these parents ever married to each other? Mother is:MOTHER FATHERUXCYION TraylorFather's birth date/ /Father's first and last nameFather's Social Security number Father's phoneFather's mailing address City State ZIPEmployerIn home Out of home Deceased EmployerMother's first and last name Mother's maiden nameMother's Social Security number Mother's birth date Mother's mailing address City StateMother's phoneZIPIn home Out of home DeceasedYes No- -- - / /2nd child's name:Father is:Were these parents ever married to each other? Mother is:MOTHER FATHERFather's birth date/ /Father's first and last nameFather's Social Security number Father's phoneFather's mailing address City State ZIPEmployerIn home Out of home Deceased EmployerMother's first and last name Mother's maiden nameMother's Social Security number Mother's birth date Mother's mailing address City StateMother's phoneZIPIn home Out of home DeceasedYes No- -- - / /Section IMore FactsAbout ChildrenAge 18 orYounger(continued)Are you afraidthat giving us factsabout someonecould cause harm(physical oremotional) to youor your child?If yes, you mightnot have to give usfacts about thatperson. You mightbe able to get the"Family ViolenceExemption."Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 83rd child's name:Father is:Were these parents ever married to each other? Mother is:MOTHER FATHERFather's birth date/ /Father's first and last nameFather's Social Security number Father's phoneFather's mailing address City State ZIPEmployerIn home Out of home Deceased EmployerMother's first and last name Mother's maiden nameMother's Social Security number Mother's birth date Mother's mailing address City StateMother's phoneZIPIn home Out of home DeceasedYes No- -- - / /4th child's name:Father is:Were these parents ever married to each other? Mother is:MOTHER FATHERFather's birth date/ /Father's first and last nameFather's Social Security number Father's phoneFather's mailing address City State ZIPEmployerIn home Out of home Deceased EmployerMother's first and last name Mother's maiden nameMother's Social Security number Mother's birth date Mother's mailing address City StateMother's phoneZIPIn home Out of home DeceasedYes No- -- - / /4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 9Other people in the homeThese people live in my home, but they dont want to apply for benefits.(Parents living with a child age 18 or younger who is applying or a spouse of a person applying should not be listed here they should fill out a box in Section H.) List the birth date only if the person is your relative. Name Relationship to you Birth date (if relative)Name Relationship to you Birth date (if relative)Name Relationship to you Birth date (if relative)Other Peoplein the HomeSection JInformation about people applying for benefits1. Does a child applying for health care travel with a family member who is a migrant farm worker? Yes No2. Is a child in the Children with Special Health Care Needs program? Yes No If yes, who?3. Is anyone an American Indian or Native Alaskan? Yes No If yes, who? What tribe?Yes No This means a person is: (1) not living with a relative,(2) age 18 or younger, and (3) a refugee.4. Is anyone an unaccompanied refugee minor?If yes, who?Help Us ServeYou BetterThis section isonly for peopleapplying forhealth-care benefits.Section KThese questions willnot be used to decideif your family canget benefits.Other Facts1. Does anyone have a disability? Yes No If yes, who?2. Is anyone getting TANF cash help for families, SNAP food benefits or health-care benefits from another state? Yes No If yes, who? Which state? When did that person last get benefits? Other FactsSection L4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 103. Has anyone been convicted of a felony that:(1) took place after August 22, 1996, and (2) involved illegal drugs? Yes No If yes, who?4. Is anyone living in a place of care such as:A homeless shelterA family violence shelterA drug treatment centerA group home Yes No Shinequal JACKSONIf yes, who?Homeless or temporary livingsituation for 90 days or less? Yes NoUXCYION TraylorIf yes, who?Homeless or temporary livingsituation for 90 days or less? Yes No5. When people break program rules, they are sometimes "disqualified" from getting benefits. People who are disqualified are sent a letter and told they can't get TANF cash help for families or SNAP food benefits.Is anyone living with you disqualified from getting TANF cash help for families or SNAP food benefits anywhere in the United States? Yes No 6. Was anyone in foster care when they were age 18 or older? Yes No If yes, who? In which state?If yes, who? In which state?Other Facts(continued)Answer 3, 4 and 5only if anyoneis applying forTANF cash help forfamilies or SNAPfood benefits.Section LOther health insuranceDoes anyone have health insurance other than Medicare, Medicaid, or CHIP? If yes, give facts below.Yes NoName of insured person (first, middle, last) Insurance company Policy number Coverage start date Coverage end date Type of coverage How much is your premium? Who pays the premium? Reason coverage ended Amount you pay each month to cover your children on this insuranceSection MMedical FactsThis section isonly for peopleapplying for TANFcash help forfamilies orhealth-care benefits.4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 11Name of insured person (first, middle, last) Insurance company Policy number Coverage start date Coverage end date Type of coverage How much is your premium? Who pays the premium? Reason coverage ended Amount you pay each month to cover your children on this insurance.4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 12Medical bills from the past 3 monthsIf anyone on your case can't pay their medical bills, Medicaid might pay them.The bills must be for services they got in the past 3 months.You need to show proof of money you get (income) for the month(s) they got services. Does anyone applying for benefits have medical bills for services they got in the past 3 months? Yes No if yes, who? (first, middle, last)Medical Facts(continued)This section isonly for peopleapplying for TANFcash help forfamilies orhealth-care benefits.Section MVehiclescar truck boat motorcycle other Yes No Does anyone own or is anyone paying for a:If yes, give facts below.Name of owner (first, middle, last) Make/ModelName of co-owner if also owned by someone outside the home Money still owed on vehicleVEHICLE 1YearVehicle is used for a person with a disability.ThingsAnyone isPaying foror OwnsSkip this sectionif you are applyingonly for health-carebenefits.Section NIf you needmore room, addmore pages withthe same facts.Name of owner (first, middle, last) Make/ModelName of co-owner if also owned by someone outside the home Money still owed on vehicleVEHICLE 2YearVehicle is used for a person with a disability.Name of owner (first, middle, last) Make/ModelName of co-owner if also owned by someone outside the home Money still owed on vehicleVEHICLE 3YearVehicle is used for a person with a disability.4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 13Things anyone is paying for or ownsYes No cash bank accounts homes and other property insurance policies stocks We need to know about items anyone owns or is paying for, such as: Does anyone own or is anyone paying for these types of items? If yes, give facts below.Item Account numberNames on account or deeds (include co-owners)ValueName and address of bank or business (to contact about item) Item 1Section NSkip this sectionif you are applyingonly for health-carebenefits.ThingsAnyone isPaying foror Owns(continued)Account numberNames on account or deeds (include co-owners)ValueName and address of bank or business (to contact about item) Item 2ItemAccount numberNames on account or deeds (include co-owners)ValueName and address of bank or business (to contact about item) Item 3ItemMoney anyone might get from other programsIf yes, mark the program anyone is waiting to hear from. Is anyone waiting for an answer on an application for one of the programs listed below? Yes No Social Security (RSDI) Supplemental Security Income (SSI) Other disability Unemployment compensation benefits MoneyComing intothe HomeSection OName of person waiting for an answer Program Name4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 14Money from jobs or training(a) working for someone else (b) training, or (c) working for themselves? Yes No Did anyone get money in the past 3 months from:If yes, give facts below.Name of person who got money from a jobIf no, list the person or place that paid the money. Hours worked Amount paidJob 1before taxes anddeductions are taken outStart date Last payment date (month/year)How often are you paid?dailyonce a weekevery 2 weeks other:once a monthtwice a monthIs this person still working at this job or in training? Yes No Was this person working for themselves? Yes No Your job may take money out of your check before taxes. These are pretax contributions. They may be for retirement savings, medical insurance premiums, a health savings account, dependent care expenses, commuter expenses or life insurance premiums. Total pretax contributions per pay period How often is it contributed Date contributed MoneyComing intothe Home(continued)Section OName of person who got money from a job Hours worked If no, list the person or place that paid the money. Amount paidJob 2before taxes anddeductions are taken outStart date Last payment date (month/year)How often are you paid?dailyonce a weekevery 2 weeks other:once a monthtwice a monthIs this person still working at this job or in training? Yes No Was this person working for themselves? Yes No Total pretax contributions per pay period How often is it contributed Date contributed Section OMoneyComing intothe Home(continued)4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 15Name of person who got money from a job Hours worked If no, list the person or place that paid the money. Amount paidJob 3before taxes anddeductions are taken outStart date Last payment date (month/year)How often are you paid?dailyonce a weekevery 2 weeks other:once a monthtwice a monthIs this person still working at this job or in training? Yes No Was this person working for themselves? Yes No Total pretax contributions per pay period How often is it contributed Date contributed 4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 16Other MoneyDoes anyone get, or expect to get, any of the types of money listed below? Yes No If yes mark other types of money anyone gets or might get soon. Social Security.Supplemental SecurityIncome (SSI).Retirement benefits.Veterans benefits.Child support anyone gets.Cash or gifts.Payments after being hurt atwork (worker's compensation).Payments after losing a job(unemployment compensation).Alimony/Spousal SupportInterest or dividends.Payments from private insuranceLoans paid to anyoneon your case.Payments to help with utilitiesRent paid to you.OtherIf anyone gets, or expects to get, any of these types of money, give the facts below. MoneyComing intothe Home(continued)Section OMONEY TYPE 1Type 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 moneyHow often are you paid?dailyonce a weekevery 2 weeksother:once a monthtwice a monthMONEY TYPE 2Type 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 moneyHow often are you paid?dailyonce a weekevery 2 weeksother:once a monthtwice a monthMONEY TYPE 3Type 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 moneyHow often are you paid?dailyonce a weekevery 2 weeksother:once a monthtwice a month4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 17Housing costsOr for a home they plan to return to? 1. Does anyone pay any of the costs listed below for the home they are living in? Yes NoIf yes, mark the coststhey have and listthe amount:Natural gas/propane PhoneWater and sewerTax on home Rent or home payment 350.00Electricity100.00Home insurance Other 100.002. Does anyone not on your case and not living in your home help pay your housing costs? Yes No Housing CostsThis section is onlyfor people applyingfor SNAP food benefits.Section PCosts to take care of othersDoes anyone have coststo take care of others?If yes, give facts below.Yes NoChild care costs so someone can work,look for work, go to training, or go to school.Examples:Child support payments, medical bills, and health insurance you pay for a child living outside the home.Costs for people with disabilities or adultswho need help caring for themselves.Alimony payments.Costs toTake Careof OthersSection QType of costCOST 1Person or company that gets the money (name, address, and phone number) Who pays the cost?First name of person who gets care or supportAmount paidHow often paid?dailyonce a weekevery 2 weeksother:once a monthtwice a monthDate last paidFor court ordered child supportlist child who gets support(provide copy of court order)Type of costCOST 2Person or company that gets the money (name, address, and phone number) Who pays the cost?First name of person who gets care or supportAmount paidHow often paid?dailyonce a weekevery 2 weeksother:once a monthtwice a monthDate last paidFor court ordered child supportlist child who gets support(provide copy of court order)4 6 1 5 1 3 3 7 5Social security number:- - Application for benefitsTexas Health and Human Services CommissionH101004/2024Page 18Medical costsDoes anyone age 60 or older, or anyone with a disability, pay medical costs Yes No If yes, mark the type of costs they pay:Doctor Hospital Medicine Health insuranceMedical CostsThis |
