Effective Date: 
6/2014

Documents


Instructions

Updated: 6/2014

PURPOSE

To authorize the Texas Health and Human Services Commission (HHSC) to use electronic data sources to verify income and resource information from an individual sponsoring an immigrant who has submitted an application for benefits.

PROCEDURE

When to Prepare

If the sponsor agrees and verbal authorization is insufficient, HHSC staff complete Form H0004 to obtain authorization.

Number of Copies

Staff obtain the sponsor’s signature on the original form during the application process or at the time of the redetermination.

Transmittal

Staff send the form to the person providing information.

Form Retention

There is no retention requirement.

DETAILED INSTRUCTIONS

Staff complete the identifying information at the top of the form. The sponsor and spouse (if applicable) must sign the form.

Having trouble viewing or downloading a form?

Get Help