Form H1841
Instructions

SNAP-CAP Application

12-2010

PURPOSE

PROCEDURE

When to Prepare

Supplemental Security Income (SSI) clients meeting SNAP-CAP requirements complete one copy of the form when automatically outreached by the Health and Human Services Commission (HHSC) state office.

The outreached individual or a designated AR may complete and sign the form. The bottom of the form may be used by clients/applicants to designate an AR.

HHSC staff must assist the client with completing the form if the client requests assistance. The HHSC staff member must initial any entries the staff member makes on the form.

Number of Copies

An original only.

Transmittal

State office automatically mails an application to individuals potentially eligible for SNAP-CAP.

A SNAP-CAP application returned to a local eligibility determination office must be faxed to the Centralized Benefit Services (CBS) Unit at 512-908-8200 the same day it is received.

Note: Form H1841 is used to apply for SNAP-CAP only.

Form Retention

See the Texas Works Manager's Guide for retention requirements.

DETAILED INSTRUCTIONS

Application for Assistance

Page 1 is the actual application for assistance.

Voter Registration — Give Form H0025, Voter Registration Application, to clients who indicate an interest in registering to vote and who meet the voting registration requirements. Authorized representatives or representative payees also may take Form H0025 to the client to complete. Mail Form H0025 when the client does not have a face-to-face interview or the client reports a change of address by telephone or by mail. If requested, assist in the completion of Form H0025.

If the applicant or client declines to register to vote during a face-to-face interview, ask the client to sign Form H1350, Opportunity to Register to Vote. Mail Form H1350 to a client who did not have a face-to-face interview who declines the opportunity to register to vote, based on receipt of Form H0025.

Voter Registration Status — Check the appropriate box under Agency Use Only and sign.

Page 2 lists an overview of SNAP-CAP, information regarding who is eligible, benefit amounts, appeal information and a number to call for more information or help.

Page 3 lists client rights and responsibilities, a Privacy Act statement and penalty information.