Downloading a Form to Your Computer
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- To notify Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) clients that they are eligible for benefits, how much the benefits will be, and how long they will get benefits.
- To give clients information about other HHSC services, appeals, and their responsibilities.
- To give TANF clients information they need about other HHSC services, such as medical services, services to families and children, and services to aged and disabled.
- To notify SNAP clients that their certification period and benefits may change depending on whether the TANF application is granted.
- To remind SNAP clients to reapply on time.
- To notify SNAP clients
- if benefits for a later month will not be issued until they give necessary proof and the date by which they must give proof when verifications are postponed.
- that their eligibility or benefits may change without advance notice because of receipt of proof which was earlier postponed.
- To notify TANF and SNAP clients about benefit increases during the certification period and to acknowledge a reported change when it does or does not increase benefits.
- To notify TANF and SNAP clients that they may request a receipt for any reported change(s).
- To give clients or representatives a way to request a fair hearing.
- To provide information about the Women, Infants, and Children (WIC) Program.
- To provide information about Certificates of Coverage to Medicaid clients whose benefits are ending.
When to Prepare
Advisors complete this form for clients certified for TANF (and prior Medicaid, if appropriate) and SNAP. Advisors also complete the form when clients report a change resulting in increased benefits or no change in benefits.
Number of Copies
Advisors complete an original and two copies.
The advisor gives an original and one copy to the client. Submit one copy to image.
If the client indicates he wants to appeal, the advisor sends the form with Form H4800, Fair Hearing Request Summary, and attachments to the hearing officer.
See the Manager's Guide for Eligibility Programs for retention requirements.
At the top, enter the client's name and address. Also enter the TANF/SNAP case number(s).
Enter the ongoing benefit amount and beginning month of certification. If a month's benefit varies from the ongoing amount, enter the month and amount in the "except" area.
First Box — On the first line, enter the ongoing benefit amount and SNAP certification period for all cases. If benefits for one or more months of the certification period differ from the ongoing benefits, enter the amount(s) and months under the exception.
Note: When appropriate, explain in the comments section why application month benefits are not provided (that is, benefits prorated to zero).
Second Box — Use this item when a verification is postponed during expedited service processing. Enter a bilingual description of the information needed. See instructions to Form H1020, Request for Information or Action, for Spanish translations of common terms.
Also enter the
- month benefits will be held pending receipt of a postponed verification, and
- date by which the proof must be received.
First Box — Use this box when the client reports a change that does not affect benefits. Enter the date the change was reported.
Second Box — Use this box when the client reports a change that increases benefits. Enter the date the change was reported.
Use this section to:
- inform households to keep self-employment records and receipts for verification purposes for future recertifications, and
- give other information to the client, such as expected variations in future allotments.
When a child fails to attend the Workforce Orientation, use the following special message:
"Although your application is certified, your household is receiving a reduced TANF amount because ( name of the required child ) failed to attend the Workforce Orientation."
"Aunque su solicitud ha sido certificada, su casa está recibiendo una cantidad reducida de TANF porque ______________________ no asistió a la Orientación de la Fuerza Laboral."
When the household is eligible for the One-Time Grandparent Payment, use the following special message:
"Your household is eligible to receive the One-Time Grandparent Payment for the following members: (list members here)"
"Su casa es elegible para recibir un Pago Único a Abuelos para los siguientes miembros: (list members here)"
When a SNAP household is designated a streamlined reporting (SR) household, use the appropriate special messages:
"Currently, we are budgeting $______ gross monthly income for your household. If at any time during your certification period, your gross monthly income goes over $______ (enter 130% FPIL amount) or your address changes, you must report the change within 10 days."
"Actualmente, el presupuesto que tenemos para su casa es de $______ en ingresos brutos mensuales. Si en cualquier momento durante el periodo de certificacion, sus ingresos brutos mensuales exceden $______ o su direccion cambia, debe informar sobre los cambios dentro de los 10 dias."
If the SR household's total gross income is greater than 130% FPIL, document the following text:
"Report all address changes within 10 days."
"Informe sobre cualquier cambio de direccion dentro de los 10 dias."
If individuals are claiming a Choices exemption for disability or caring for a disabled child use this statement:
"You must apply for assistance with the Social Security Administration and provide proof of the application at your next TANF interview."
"Tiene que solicitar asistencia de la Administración del Seguro Social y presentar prueba de la solicitud en su próxima entrevista de TANF."
Free Legal Service — Enter information about free legal services. If none, enter "none available."