Texans can dial 2-1-1 (option 6) for information on COVID-19 and local community resources on health care, utilities, food, housing and more. More COVID-19 information.
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.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- 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.
To advise the couple requesting a resource assessment of their spousal protected resource amount.
When to Prepare
Complete Form H1274 when a resource assessment has been completed.
Number of Copies
Complete an original and two copies if form is computer-entered. Complete an original and three copies if completed by hand.
Send the original to the client. Send one copy to the spouse.
Keep a copy of Form H1274 in the case record for three years after the case is denied.
Client Name — Enter the last name, comma, first name, space and middle initial. Do not exceed 22 characters. Shorten if necessary.
Date of Birth — Enter (in MMDDYY format) the individual's date of birth.
Name of Medical Care Facility or Applicable Waiver — Enter the name of the facility in which the client lives or name of waiver program.
Address of Medical Care Facility or Waiver Client —
- Street or Box Number — Enter the street or box number of the facility.
- City — Enter city in which facility is located.
- State — Enter the two-letter postal service abbreviation; for example, TX.
- ZIP code — Enter the facility's ZIP code, up to nine digits.
Date of Admission to Medical Care Facility or Waiver Application Date — Enter the date of medical care facility entry or date of waiver application in MMDDYY format.
Date Assessment is Completed — Enter (in MMDDYY format) the date the assessment is completed.
Social Security Number — Enter the individual's nine-digit Social Security account number.
Social Security Claim Number — Enter the individual's Medicare claim number.
Assessment Number — Make no entry; reserved for future use.
BJN — Enter the eight-digit budgeted job number of the person completing the assessment. If BJN is not known, enter employee number.
Mail Code — Enter four-digit mail code of the person completing the assessment.
County Code — Enter the three-digit code of the county in which the individual resides.
Invoice Number — Make no entry; reserved for future use.
Resources — Enter the appropriate resources with dollar value as of 12:01 a.m. on the first day of the month of institutionalization.
Total Countable Resources — Enter the total dollar value of all resources listed above.
Spouse Share — Enter one-half of the amount given above.
Spouse Protected Resource Amount — Enter the spousal protected resource amount.
Spouse Allowance — Enter the current maximum spousal allowance.