Form H1084, Certification for Warrants Lost, Destroyed, Stolen or Not Received

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Documents

Effective Date: 7/2022

Instructions

Updated: 7/2022

Purpose

  • To notify Texas Health and Human Services (HHS) Accounting Operations within HHS Fiscal Management Services that the recipient of a One-Time TANF for Relatives warrant (check) is requesting a reissuance of the warrant lost, destroyed, stolen or not received. Note: For warrants not received, wait at least 10 business days after warrant issuance before submitting Form H1084.
  • To get the recipient’s written and signed statement certifying they have not endorsed or otherwise received a One-Time TANF for Relatives warrant. Also that they understand they must return the warrant to a local HHS office or to the address on the form if they find or receive the first warrant.
  • To provide a record of a recipient's statement for prosecution if HHS discovers perjury or intentional program violation (IPV).

Procedure

When to Prepare

Prepare Form H1084 when the recipient reports a One-Time TANF for Relatives warrant as lost, destroyed, stolen or not received.

Number of Copies

  • Fax a copy of the completed form to HHS Accounting Operations.
  • Provide a copy to the household.
  • Upload a copy in the electronic case record.

Transmittal

Fax the request to 512-487-3400 or scan and email to HHS Warrant Issuance.

Detailed Instructions

Part I 

Warrant Information (Completed by HHS Staff) — HHS staff complete Part I to provide their and the warrant recipient’s contact information to HHS Accounting Operations.

Employee Name — Enter the HHS employee’s name who is requesting reissuance.

Employee No. — Enter the employee number of the HHS employee requesting reissuance.

Phone No. — Enter the HHS employee’s phone number.

Date — Enter the date of the request.

Owner Name — Enter the name of the TANF caretaker or payee relative who will receive the payment.

Treasury Warrant No. — Enter the treasury warrant number found through TIERS inquiry. 

Warrant Amount — Enter the One-Time TANF for Relatives benefit amount of $1,000 that should appear on the warrant. This will also be the amount shown through TIERS inquiry.

Warrant Date — Record the warrant date displayed through TIERS inquiry.

Owner’s Mailing Address — Enter the mailing address of the TANF caretaker or payee relative who will receive the reissued warrant.

Part II

Certification Statement (Completed by TANF Recipient) — The TANF recipient completes Part II to certify if their warrant was lost, destroyed, stolen or not received.

I certify the Treasury warrant described above was — Check the appropriate box for applicable situation.

Signature — After reading the certification statement, the TANF caretaker or payee relative who is to receive the reissued warrant signs the form. If there is an authorized representative (AR) for the TANF caretaker or payee relative, the AR signs the form. 

Date — The TANF caretaker or payee relative who is to receive the reissued warrant enters the date they sign the certification statement. If there is an AR for the TANF caretaker or payee relative, the AR dates the form.

Print Name (if authorized representative for owner) — If there is an AR for the TANF caretaker or payee relative, the authorized representative signs, dates and prints their name.

Inform the recipient that if they receive the cancelled warrant after requesting reissuance, they must return the cancelled warrant to a local HHS office or send by mail to the address on the form. 

The HHS eligibility employee completing the form indicates approval to reissue the warrant by marking the appropriate checkbox, yes or no.