Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 



Updated: 5/2017


  • To give workers a method to refer designated applicants/individuals to the Social Security Administration (SSA) to obtain an original, corrected or replacement Social Security card.
  • To give workers a method to refer legal aliens without Department of Homeland Security (DHS) work authorization to SSA to obtain a Social Security number (SSN).
  • To verify and document the enumeration process has been completed.


When to Prepare

Complete the form when the applicant:

  • cannot provide an SSN;
  • provides an SSN but his name and/or date of birth is incorrect on SSA records;
  • presents an expired Form SSA-5028, Receipt for Application for a Social Security Number;
  • presents Form SSA-5028 or SSA-2853 at certification but at Temporary Assistance for Needy Families (TANF) periodic review, he cannot provide an SSN;
  • furnishes an invalid SSN (an SSN that Texas Eligibility Redesign System (TIERS) will not accept); or
  • is a legal alien without DHS work authorization.

Number of Copies

An original and one copy.


Give the original to the applicant (one for each member needing an SSN) to take to the Social Security office. File the copy in the case record on top of the current Form H1010, Texas Works Application for Assistance – Your Texas Benefits.

Forms Return

SSA returns completed Forms H1106 daily.

When the form is returned, determine if SSA changed the applicant's name or date of birth. If so, update the information in TIERS. If the applicant's name or date of birth is not changed, a discrepancy report will result.

File the original in the case record under "legal" and discard the copy.

Form Retention

Keep a copy according to the retention requirements for case records. See the Manager's Guide for Eligibility Programs.

Detailed Instructions

Case Name — Enter the Texas Health and Human Services Commission (HHSC) case name.

Client Name — Enter the name of the person you are referring to SSA.

Client Date of Birth — Enter the date of birth of the person you are referring to SSA.

Client, Case or EDG Number — Enter only one of these numbers on the form. The client number is preferred, then case or eligibility determination group (EDG) number.

HHSC Mailing Address — Enter the local office mailing address.

Social Security Admin. District/Branch Office Enumeration Unit — Enter the local office mailing address.

Reasons for form — Check the box that indicates the reason the client has been sent to SSA to apply for an SSN. Only check box 1 or 2, not both. Always check box 3 to request a receipt.

Signature – Advisor — Sign the form.

Date — Enter the date of signature.

Telephone — Enter advisor’s telephone number. Include the area code.

For Social Security Administration Use Only — This information is filled out by SSA staff only.

Page 2

When processing the form at a TANF periodic review, as noted in the fourth bullet under "When to Prepare" of these instructions, staff must indicate on the top of Page 2 that the form must be returned by SSA by the 60th day after it is given to the client.