Texas Works Handbook
Forms Table of Contents
For information about forms accessibility, contact DADS at handbookfeedback@dads.state.tx.us
| AT-Report | Administrative Terminal Report | ||
| FNS-135 | Affidavit of Return or Exchange of Food Coupons | ||
| G-845S | Document Verification Request | ||
| H0003 | Authorization to Furnish Information | ||
| H0007-A | Activity Record | ||
| H0025 | HHSC Application for Voter Registration | ||
| H0025-S | HHSC Application for Voter Registration (Spanish) | ||
| H0050 | Parent Profile Questionnaire | ||
| H0070 | Food Stamps Streamlined Reporting (Income Calculation Worksheet) | ||
| H0074 | Hospital CHIP Referral | ||
| H0401 | HIPAA - Privacy Notice | ||
| H0401-S | HIPAA - Privacy Notice (Spanish) | ||
| H0402 | HIPAA - Explanation of Medicaid Privacy Rights | ||
| H0403 | HIPAA - Explanation of Health Information Privacy Rights | ||
| H0901 | HHSC Enhanced Data Gathering Worksheet | ||
| H0920 | Notice from the Community Organization Helping You | ||
| H0926-CP-AA | Sharing Facts About Me and My Case | ||
| H0926-CP-AA-S | Sharing Facts About Me and My Case (Spanish) | ||
| H0926-CP-CA | Sharing Facts About Me and My Case | ||
| H0926-CP-CA-S | Sharing Facts About Me and My Case (Spanish) | ||
| H1000-A | Notice of Application | ||
| H1000-B | Record of Case Action | ||
| H1000-C | Secondary Client Input | ||
| H1001 | Application for Benefit Assistance From the Voluntary Agency(VOLAG) Fax Coversheet - Applications ONLY (Form H1010) | ||
| H1002 | Client Record Merge/Separate Request | ||
| H1004 | Request for Form H1000-B | ||
| H1005 | Work Planning and Delinquency Report | ||
| H1007 | Eligibility for Food Stamps and Medicaid | ||
| H1008 | Authorization for Cancellation or Issuance of Public Assistance Warrants | ||
| H1008-A | Warrant Inquiry/EBT Benefit Conversion and Affidavit for Non-receipt of Warrant | ||
| H1009 | TANF/Food Stamp Benefits Notice of Eligibility | ||
| H1009-A | TANF/Food Stamp Notice of Eligibility - Client Rights/Responsibilities Information | ||
| H1010 | Texas Works Application for Assistance - Your Texas Benefits (English and Spanish) | ||
| H1010-A | Application for Assistance - Part A: Information You Need to Know | ||
| H1010-B | Application for Assistance - Part B: Information We Need to Know | ||
| H1010-R | Your Texas Works Benefits: Renewal Form | ||
| H1011 | Application for Medicaid for Youth Transitioning from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program | ||
| H1011-A | Medical Renewal Form for Youth Transitioned from Foster Care or an Approved Unaccompanied Refugee Minor's Resettlement Program | ||
| H1012 | Immunization Record | ||
| H1013 | TWC Income Information Request | ||
| H1014 | Application Information for Children's Health Insurance Program (CHIP), Children's Medicaid, and CHIP Perinatal Coverage | ||
| H1014-S | Application Information for Children's Health Insurance Program (CHIP), Children's Medicaid, and CHIP Perinatal Coverage (Spanish) | ||
| H1015 | Children's Medicaid Renewal | ||
| H1015-A | Children's Medicaid Renewal - Final Reminder | ||
| H1015-S | Children's Medicaid Renewal (Spanish) | ||
| H1016 | Supplemental Security Income Referral | ||
| H1017 | Notice of Benefit Denial or Reduction | ||
| H1017-A | Notice of Benefit Denial or Reduction - Client Rights/Responsibilities | ||
| H1017-B | Transitional Medicaid | ||
| H1017-P | Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons | ||
| H1017-PS | Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons (Spanish) | ||
| H1018 | Overpayment Claim | ||
| H1019 | Report of Change | ||
| H1019-F | Report of Change - FFCHE | ||
| H1019-FS | Report of Change - FFCHE (Spanish) | ||
| H1019-S | Report of Change (Spanish) | ||
| H1020 | Request for Information or Action | ||
| H1020-A | Sources of Proof | ||
| H1021 | Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account | ||
| H1022 | Notice to Apply Benefits in a Dormant Lone Star Food Account to a Food Stamp Claim | ||
| H1023 | Installment Payment Agreement - Debit of a Lone Star Food Account | ||
| H1024 | Subject: Self-Declaration Notice | ||
| H1026 | Verification of Railroad Retirement Benefits | ||
| H1026-FTI | Verification of Railroad Retirement Benefits - FTI | ||
| H1027-A | Medicaid Eligibility Verification | ||
| H1027-B | Medicaid Eligibility Verification - MQMB | ||
| H1027-C | Medicaid Eligibility Verification - QMB | ||
| H1027-F | Proof of Health Care Coverage | ||
| H1028 | Employment Verification | ||
| H1028-S | Employment Verification (Spanish) | ||
| H1029 | Notice of Case Action | ||
| H1030 | Simplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance | ||
| H1030-S | Simplified Nutritional Assistance Program (SNAP) Lone Star Card Assistance (Spanish) | ||
| H1031 | Case Record Transfer | ||
| H1032 | Request for Cases/Charge Out Change | ||
| H1033 | Notice of Transfer | ||
| H1036 | Refugee Cash Assistance Verification Form | ||
| H1038 | Medical Facility Referral | ||
| H1039 | Medical Insurance Input | ||
| H1040-A | Application Suspense File Card | ||
| H1040-B | Review Suspense File Card | ||
| H1040-C | Change Suspense File Card | ||
| H1041 | Worker Activity Log | ||
| H1043 | Appointment Schedule | ||
| H1044 | Standby Log | ||
| H1046 | Inpatient Medical Services Certification | ||
| H1046-S | Inpatient Medical Services Certification (Spanish) | ||
| H1049 | Client's Statement of Self-Employment Income | ||
| H1050 | Check Verification | ||
| H1057 | Declaration of Informal Marriage | ||
| H1059 | Interview Observation Instrument | ||
| H1060 | Case Preparation Guide | ||
| H1065 | Tuition and Fee Exemption Letter | ||
| H1072 | One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement | ||
| H1073 | Personal Responsibility Agreement | ||
| H1074 | SNAP Force Change Request | ||
| H1075 | Welfare Reform Force Change Request | ||
| H1076-A | Notice of TANF State Time Limits | ||
| H1076-B | Notice of TANF State Time Limit Months Used/Changed/Corrected | ||
| H1076-C | Notice of End of TANF State Time Limit/Hardship Exemption | ||
| H1077 | Notice of TANF Federal Time Limits | ||
| H1079 | Qualifying Quarters of Social Security Earnings | ||
| H1082 | TANF Grandparent Supplement Payment Request | ||
| H1084 | Certification for Warrants Lost, Destroyed, Stolen or Not Received | ||
| H1086 | School Attendance Verification | ||
| H1087 | Verification of Texas Health Steps (THSteps) Checkup | ||
| H1088 | Verification of Parenting Skills Training | ||
| H1093 | THSteps Extra Effort Referral | ||
| H1094 | Notice of TANF-SP Time Limit | ||
| H1094-S | Notice of TANF-SP Time Limit (Spanish) | ||
| H1095 | Treatment Facility Fraud Referral | ||
| H1096 | Notification Letter | ||
| H1097 | Affidavit for Citizenship/Identity | ||
| H1097-S | Affidavit for Citizenship/Identity (Spanish) | ||
| H1100 | Addendum Income Worksheet | ||
| H1101 | TANF Worksheet | ||
| H1102 | TANF Worksheet for Special Reviews and Denials | ||
| H1103 | Verification of TANF Eligibility | ||
| H1104 | 90% Earned Income Deduction (EID) Eligibility and Tracking | ||
| H1105 | SNAP Expedited Screening Sheet | ||
| H1106 | Enumeration Referral | ||
| H1106-A | Proofs You Need to Apply for a Social Security Number Card | ||
| H1107 | Request for Forced Change of Medical Coverage | ||
| H1108 | Job History Information | ||
| H1110 | PIN Order Discrepancy Verification | ||
| H1111 | Card Order Discrepancy Verification | ||
| H1113 | Application for Prior Medicaid Coverage | ||
| H1118 | Spend Down Information Sheet (Medically Need Program) | ||
| H1119 | Medical Programs Income Worksheet | ||
| H1120 | Medical Bills Transmittal/Insurance Information | ||
| H1122 | Medicaid Action Notice | ||
| H1122-A | Medicaid Information - Client Rights/Responsibilities | ||
| H1131 | Individually Identifiable Health Information Fax Transmittal | ||
| H1133 | Account Verification | ||
| H1134 | Assistance Statement Verification | ||
| H1135 | Child Care Expense Verification | ||
| H1136 | Child Support Verification | ||
| H1137 | Confirmation of Office Visit Work/School Excuse | ||
| H1138 | Living Arrangement Verification | ||
| H1139 | Medical Expense Verification | ||
| H1140 | Verification of Benefits | ||
| H1146 | Medicaid Report | ||
| H1146-M | Medicaid Report (Manual) | ||
| H1155 | Request for Domicile Verification | ||
| H1161 | Eligibility Case Reading | ||
| H1162 | Lone Star Card Insert | ||
| H1163 | TWC Employment Registration | ||
| H1172 | EBT Card, PIN and Data Entry Request | ||
| H1173 | EBT Card Issuance and PIN Self-Selection/Issuance Log | ||
| H1174 | Inventory of EBT Cards/PIN Packets | ||
| H1175 | Authorization for Administrative Terminal Application Action | ||
| H1177 | Transmittal and Receipt for Controlled EBT Documents | ||
| H1182 | TANF Client Fee Notification Letter | ||
| H1183 | EBT Pocket Guide | ||
| H1184 | Benefit Issuance Schedule | ||
| H1185 | Welcome to Your Lone Star Card | ||
| H1185-S | Welcome to Your Lone Star Card (Spanish) | ||
| H1186 | OIG Match Action Alert | ||
| H1187 | Welcome to Texas Health Steps Medicaid! | ||
| H1188 | Common Questions Asked About Texas Health Steps and Your Child's Medicaid | ||
| H1190 | Ending TANF Five Year Freeze Out Disqualification | ||
| H1240 | Request for Information from Bureau of Veterans Affairs and Client's Authorization | ||
| H1265 | Presumptive Eligibility Budget Sheet | ||
| H1266 | Notice of Presumptive Eligibility for Pregnant Women | ||
| H1267 | Presumptive Eligibility - Notice of Ineligibility | ||
| H1271 | Presumptive Eligibility Application Packet Referral Letter | ||
| H1350 | Opportunity to Register to Vote | ||
| H1550 | Out of State NBCCEDP Verification | ||
| H1551 | Treatment Verification | ||
| H1701 | Child Support, TANF Foster Care and TANF/Medicaid Case Information Exchange | ||
| H1706 | Good Cause Recommendation | ||
| H1708 | Report of Noncooperation (Manual Version) | ||
| H1708-A | Report of Noncooperation (Automated Version) | ||
| H1710 | Payment Identification/Identificacion Pagado | ||
| H1712 | Explanation of Child/Medical Support, Family Violence and Good Cause | ||
| H1713 | Service Plan for Family Violence Option and Report of Good Cause | ||
| H1714 | Notice of Grant Jeopardy | ||
| H1715 | Notice of Excess Payment | ||
| H1716 | Notice of Grant Jeopardy/Excess Payment - Transfer to TP 20 | ||
| H1717 | Notice of Grant Jeopardy/Excess Payment - Denial | ||
| H1718 | Notice of Benefit Denial | ||
| H1719 | Notice of Excess Payment | ||
| H1750 | Child Support Referral | ||
| H1800 | Receipt for Application/Medicaid Report/Verification/Report of Change | ||
| H1801 | SNAP Worksheet | ||
| H1802 | Voluntary Withdrawal from Temporary Assistance for Needy Families (TANF) | ||
| H1803 | Food Stamp Identification Card | ||
| H1804 | Mail Label | ||
| H1805 | SNAP Food Benefits: Your Rights and Program Rules | ||
| H1808 | Notice of Food Stamp Employment Services Registration | ||
| H1816 | SNAP E&T Noncompliance Report | ||
| H1817 | Food Stamp E&T Information Transmittal | ||
| H1822 | ABAWD E&T Work Requirement Verification | ||
| H1823 | Work Requirement Documentation | ||
| H1825 | Entitlement to Restored Benefits | ||
| H1826 | Case Information Release | ||
| H1829 | Children's Medicaid Renewal Proof | ||
| H1829-S | Children's Medicaid Renewal Proof (Spanish) | ||
| H1830 | Application/Review/Expiration/Appointment Notice | ||
| H1830-I | Interview Notice (Applications or Reviews) | ||
| H1830-L | Children's Medicaid Renewal Notice | ||
| H1830-LS | Children's Medicaid Renewal Notice (Spanish) | ||
| H1830-R | Texas Works Renewal Notice | ||
| H1830-W | Women's Health Program Review/Expiration Notice | ||
| H1831 | Adjunctive Eligibility Letter | ||
| H1831-S | Adjunctive Eligibility Letter (Spanish) | ||
| H1832 | Affidavit for Meal Providers to the Homeless | ||
| H1833 | Cover Letter - Other Medicaid Ending | ||
| H1834 | Cover Letter - Other Medicaid Denied | ||
| H1836-A | Medical Release/Physician's Statement | ||
| H1836-AS | Medical Release/Physician's Statement (Spanish) | ||
| H1836-B | Medical Release/Physician's Statement | ||
| H1836-BS | Medical Release/Physician's Statement (Spanish) | ||
| H1837 | Physician's Statement of Permanent Disability | ||
| H1840 | SNAP Food Benefits Renewal Form | ||
| H1841 | SNAP-CAP application | ||
| H1842 | SNAP-CAP renewal application | ||
| H1843 | FNS Authorized SNAP-CAP Benefit Increase Notice | ||
| H1844 | Refugee Cash Assistance Employment Services Contractor Referral | ||
| H1844-A | Contractor Receipt Log for Initial RCA Referrals (Form H1844) | ||
| H1845 | Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facility Review | ||
| H1846 | Facility Authorized Representative Interview | ||
| H1847 | Reminder to Submit Form H1852 | ||
| H1851 | Reference Guide for Drug and Alcohol Treatment (D&A)/Group Living Arrangement (GLA) Facilities | ||
| H1852 | List of Resident Participants in the Food Stamp Benefits Program | ||
| H1853 | Documentation of Findings for Form H1852 | ||
| H1855 | Affidavit for Nonreceipt or Destroyed Food Stamp Benefits | ||
| H1856 | SNAP Out-of-State Intentional Program Violations | ||
| H1857 | Landlord Verification | ||
| H1858 | Items We Need When You Apply for Benefits | ||
| H1858-S | Items We Need When You Apply for Benefits (Spanish) | ||
| H1859 | Social Security Administration Benefits for People with Disabilities Receiving TANF | ||
| H1860 | TANF Social Security Outreach Letter | ||
| H1861 | Federal Tax Information Destruction Log | ||
| H1862 | Federal Tax Information Transmittal Memorandum | ||
| H1863 | Federal Tax Information Removal Log | ||
| H1864 | Federal Tax Information Fax Transmittal | ||
| H1865 | Federal Tax Information Transmittal Log | ||
| H1866-A | Notice of Food Stamp Distribution | ||
| H1867 | Texas Women's Health Program Application Form | ||
| H1867-R | Women's Health Program Medicaid Application | ||
| H1867-RS | Women's Health Program Medicaid Application (Spanish) | ||
| H1867-S | Texas Women's Health Program Application Form (Spanish) | ||
| H1868 | Application for Health Care Benefits | ||
| H1868-S | Application for Health Care Benefits (Spanish) | ||
| H1869 | Renewal for Health Care Benefits | ||
| H1869-S | Renewal for Health Care Benefits (Spanish) | ||
| H1870 | School Enrollment Verification Form | ||
| H1870-S | School Enrollment Verification Form (Spanish) | ||
| H1871 | Outreach Letter - HCFFCHE | ||
| H1871-S | Outreach Letter - HCFFCHE (Spanish) | ||
| H1898 | Restored Benefits Documentation | ||
| H1901 | TIERS Data Collection Worksheet | ||
| H2067 | Case Information | ||
| H2340-OS | Medicaid for Breast and Cervical Cancer | ||
| H2580 | TANF Employment Services Notice | ||
| H2581 | Choices Noncooperation Report | ||
| H2583 | Choices Information Transmittal | ||
| H2588 | Workforce Orientation Referral | ||
| H2748 | Choices/Food Stamp Employment Services Appointment Notice | ||
| H2776 | Job Search Worksheet for TANF Employment Hardship Exemption | ||
| H2776-S | Job Search Worksheet for TANF Employment Hardship Exemption (Spanish) | ||
| H3037 | Report of Pregnancy | ||
| H3038 | Emergency Medical Services Certification | ||
| H4100 | Money Receipt | ||
| H4701 | HHSC Out Card | ||
| H4744 | Batch Control Sheet | ||
| H4745 | Batch Control Ledger | ||
| H4800 | Fair Hearing Request Summary | ||
| H4800-A | Fair Hearing Request Summary (Addendum) | ||
| H4803 | Notice of Hearing | ||
| H4804 | Request and Authorization for Fair Hearing Record to Remain Open | ||
| H4807 | Action Taken on Hearing Decision | ||
| H4808 | Notice of Change in Applied Income/Notice of Denial of Medical Assistance | ||
| H4837 | Fair Hearings Evidence Packet Cover Letter | ||
| H4857 | Notice of Decision, Administrative Disqualification Hearing | ||
| H4870 | Client Complaint of Discrimination (English-Spanish Version) | ||
| H5799 | TANF Warrant/Envelope | ||
| LSC | Lone Star Card | ||
| LSCM | Lone Star Card Mailer | ||
| LSCRS | Lone Star Card Registration Sticker | ||
| LSCS | Lone Star Card Sleeve | ||
| PIN | Personal Identification Number (PIN) Packet | ||
| RA-01 | TANF Activity Report | ||
| RA-01C | TANF Activity Report/Regional Summary by County | ||
| RA-04 | TANF Caseload Information by Ethnicity | ||
| RA-07AB | TANF Fraud/Non-Fraud Recoupment Completion Notice | ||
| RA-103 | TANF Time Limits - Countable Month Precedes Notification Effective Date | ||
| RA-109 | Excess TANF Benefit for Client Already at FTL Month 60 | ||
| RA-110 | TANF SIG 0, 2, or 9 Client at FTL Month 60 | ||
| RA-18 | TANF Non-Fraud Recoupment Initiation Notice | ||
| RA-24 | List of Warrants on Hold | ||
| RA-58 | Medicaid Report Form Case Listing | ||
| RA-60 | Clients Incorrectly Dually Certified for TANF/Medical Programs and SSI | ||
| RA-66 | TANF and Texas Works Cases with Unenumerated Clients | ||
| RA-79 | GWS TIER Discrepancy Report | ||
| RA-80 | JOBS Sanctioned Clients with Tier Level 8 | ||
| RA-81 | Adjustment of TANF Time Limit Months | ||
| RA-90 | JOBS Sanctioned Clients with Overlapping Good Cause | ||
| RA-93 | JOBS Sanctioned Clients - Notification Effective Date Change | ||
| RA-97 | Voluntary Quit Penalties: Potential Food Stamp Impact | ||
| RF-01 | Food Stamp Activity Report | ||
| RF-03 | Food Stamp Household Size and Type by Bonus Value (Issuance) | ||
| RF-07E-1 | EBT Reconciliation Exception Report | ||
| RF-14 | Monthly Food Stamp Reminder | ||
| RF-158-1 | Employment and Training Program Noncompliance and Sanction Reminder | ||
| RF-229 | TANF Case Adjusted or Denied Due to Time Limit Policies - FS Case Not Converted | ||
| RF-30-1-3 | Food Stamp Cases Whose Other Income was Insufficient to Handle TANF $30 or 1/3 Changes | ||
| RF-36 | More Than One Food Stamp Benefit Authorized | ||
| RF-49 | Pending Application Report | ||
| RF-50 | Food Stamp Timeliness Summary Report | ||
| RF-51 | Food Stamp Timeliness Detail Report | ||
| RF-54 | Food Stamp Timeliness Worker Summary Report | ||
| RF-66 | Food Stamp Cases with Unenumerated Clients | ||
| RG-01 | NOA Report | ||
| RG-03 | Client File Referral Report | ||
| RG-07 | Budgeted Job Number Realignment Card | ||
| RG-09 | Bendex Information Memorandum | ||
| RG-09A | Bendex Memorandum Summary | ||
| RG-101 | Income and Eligibility Verification Data | ||
| RG-150-1 | Employer New Hire Reporting (ENHR) Worker Report | ||
| RG-150-1-A | Employer New Hire Reporting (ENHR) Worker Report | ||
| RG-150-2-A | Employer New Hire Reporting (ENHR) Unit Report | ||
| RG-30 | Timeliness of Application Disposition | ||
| RG-31 | Application Disposition Report | ||
| RG-83 | SSN Maintenance Memorandum | ||
| RG-83B | SSN Maintenance Follow-Up Tracking Report | ||
| RG-86 | Income Information Request | ||
| RG-87 | Unemployment Claim Data | ||
| RLSM | Request for Lone Star Materials | ||
| RN-01 | Income Assistance Medical Programs Activity Report | ||
| RN-23 | Notice of Future Case Action | ||
| RN-24-2 | Monthly Report of Cases on Hold Code 3 (Type Programs 43 and 48) | ||
| RN-74 | TP 40 End Date Review Required | ||
| RN-75 | TP 40 End Date Correction Required | ||
| RN-76 | TP 40 End Date Changed | ||
| RP-24B | Daily Notice of Cases/Benefits Placed On Hold | ||
| SAMPLE1 | Potential Eligibility Prescreening Record | ||
| SCRF | Second Cardholder Request Form | ||
| SSA-1610-U2 | Public Assistance Agency Information Request | ||
| SSA-2853 | Message from Social Security | ||
| SSA-3288 | Social Security Administration Consent for Release of Information |