Downloading a Form to Your Computer
- 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 application. 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 record proof and documentation of income, resources and questionable information when used with Form H1010.
- To compute gross or net income to decide eligibility and allotment.
- To record the certification period and basis of issuance for eligible households or the reason for denial.
- To record work registration status for all household members.
- To record changes in household circumstances reported during the certification period.
Workers complete one copy of Form H1801 if needed and image it in the case file with Form H1010.
Workers complete one copy of Pages 1-3 and/or Page 4 of Form H1801 if, during the certification period, it is necessary to recompute SNAP income to find an overpayment or to record changes in household circumstances.
See Texas Works Managers Guide for retention requirement.
Enter case name and other identifying information. Check all yes/no items. Enter case name, date and location of case record if a household member has applied for TANF. In the residence section, enter verification method used.
STEP 1 — RESOURCE DETERMINATION
List all nonexempt resources and the value of each. Enter the total value of all resources. In the space provided, give a brief description of the household's circumstances.
STEP 2 — GROSS INCOME DETERMINATION
1. Gross Earned Income — List the names of all household members who have countable earnings and the gross amount, including cents. Include here the net self-employment income for each household member. Enter zero if a member loses money in a self-employment operation.
Note: If a household member has a deductible self-employment farm loss, complete Form H1049, Page 3, Section III.
If more than four household members have countable earnings, enter the remaining income in Item 1d as "others" and identify in the documentation section.
Do not list any exempt earned income. Document any exempt earned income in the verification/documentation space or on an attached sheet.
Add Items 1a, 1b, 1c and 1d, and enter the household's total gross earned income in Item 1e.
2. Unearned Income — List all unearned income in Items 2a through 2g, including cents. Include the total net self-employment unearned income. Add Items 2a through 2g and enter the household's total gross unearned income in Item 2h.
Do not list any exempt unearned income. Document any exempt unearned income on the verification/documentation space or on an attached sheet.
3. Total Gross Income — Add the totals from Items 1e and 2h, and enter in Item 3.
4. Is Household Subject to Gross Income Test? — If yes, answer Question 5. If no, skip Question 5 and go to Step 3.
5. Is Household Eligible Based on Gross Income? — If yes is checked, go to Step 3. If no is checked, go to Step 7.
STEP 3 — NET INCOME DETERMINATION
1. Total Gross Income — Enter the total gross income from Step 2, Item 3.
2. Earned Income Deduction — Compute 20% of the total gross earned income in Step 2, Item 1e and enter the amount here, including cents.
3. Farm Loss — Enter the remaining farm loss amount listed on Form H1049, Page 3, Part III, Item D.
4. Standard Deduction — Enter the amount of the standard deduction.
5. Medical Costs — Enter either:
- the standard medical expense minus $35; or
- actual medical expenses including cents minus $35.
Document the verification provided and the computation used to determine the medical expense amount. Also, document that the client incurred more than $35 of medical expenses to allow the standard medical expense.
6. Homeless Shelter Standard — Enter the amount of the homeless shelter standard.
7. Monthly Dependent Care Costs — Enter the amount of the client's monthly unreimbursed cost for dependent care including cents. Document the amounts used to determine the monthly dependent care expense.
8. Child Support Paid to/for Non-Household Member — Enter the total amount of legally obligated child support actually paid to or for an individual outside the household. Allowable child support deductions include cash support, medical support and third-party payments.
Document the verification provided as proof of the household's legal child support obligation, amount of the legal obligation and the actual amount paid.
9. Total Deductions — Add Items 2, 3, 4, 5, 6, 7 and 8 and enter the total in Item 9.
10. Adjusted Gross Income — Subtract Item 9 from Item 1 and enter the amount here.
11. Shelter Expenses — Enter the client's housing expenses, including cents, in 11a. If the client claims the standard utility allowance, basic utility allowance or phone allowance, enter this amount in Item 11b. Add 11a and 11b and enter in 11d. If there are no shelter costs, enter zero. In Item 11e, enter 50% of the adjusted income from Item 10. Subtract Item 11e from 11d and enter the difference in Item 11f.
Expedited Determinations Only — If actual utility costs are claimed, list the total utility costs in Item 11c or separately in Items 11c(1) through 11c(4). Total 11a and 11c or 11c(1) through 11c(4) and enter in 11d.
Note: If a homeless household receives the homeless shelter standard, enter this amount in Item 6. Do not enter any housing or utility expenses in Item 11 when using the homeless shelter standard.
12. Maximum Excess Shelter — Enter the maximum excess shelter amount. Exception: If the household is not subject to this deduction, leave blank.
13. Net Income — If the household is not subject to the maximum excess shelter deduction, subtract Item 11f from Item 10 and enter the difference.
If the household is subject to the maximum excess shelter deduction, subtract the lesser amount of Item 11f or Item 12 from Item 10 and enter the difference.
14. Rounded Net Income — If Item 13 is one through 49 cents, round to the next lower dollar; if 50 through 99 cents, round to the next higher dollar. Enter the rounded net income.
15. Is the household eligible based on net income?
If the household is subject to the net income test:
- Check Yes if the rounded net income does not exceed the net income limit.
- Check No if the rounded net income exceeds the net income limit.
- Check NA if the household is categorically eligible.
16. Number of Certified Members — Enter the number of household members eligible for SNAP benefits.
17. Monthly Allotment — Enter the client's monthly allotment.
18. Prorated Allotment — Enter the prorated allotment, if applicable.
19. Months Covered by First Budget — Enter the inclusive months covered by the first budget. This is the length of the certification period, unless using additional budgets.
20. Months Covered by Second Budget — Enter the inclusive months covered by the second budget if a double budget is used.
STEP 4 — MANAGEMENT
STEP 5 — EMPLOYMENT SERVICES
STEP 6 — BASIS OF CERTIFICATION OR DENIAL
Certified — If the household is eligible for benefits, enter the first benefit month in From and the last month the client is eligible in To.
Special Review Date — Enter month/year of special review, if appropriate. Enter special review reason code.
Reason Code — Document if the household does or does not meet the streamlined reporting (SR) criteria. Enter one of the following codes to designate the type case:
- Code 1-SR case with gross income less than or equal to 130% FPIL;
- Code 2-SR case with gross income greater than 130% FPIL; or
- Code 3-non SR case.
- Special Review and Certification Period Explanation — Document the reason for the length of the assigned certification period.
- Denial Explanations — Document the reason the client is ineligible.
STEP 7 — SNAP FORMS AND REFERRALS
Check the correct boxes to show if the forms and referrals listed were given to the client. Enter names of the household members for whom Forms H1106 were completed, the date Form H1106 was returned by SSA, and any related information. Check the type referrals made and issuance method used, and enter the corresponding code. Sign and date the form.
In this space record clarification of questionable information, collateral contacts, work registration exemptions, explanation for any members now certified elsewhere, home visits, and computations. Enter any other required verifications.
Also use this section to explain any differences between information given by the client on Form H1010-B and information recorded on Form H1801.Example: total shelter costs reported as opposed to the total amount allowed; earned income reported that differs from the advisor's projected average; and individual medical costs and the computation used for the amount in Step 3, Item 5.
Identify documentation whether on Form H1801 or additional sheets, referring to the step and item number on the form, such as "Step 2, Item 2a" followed by a description of the verification used.
Document Changes — Document changes in gross income, allowable deductions, or household circumstances during the certification period.
Adjustments — Enter and compute the client's eligibility and allotment for changes during the certification period. Document the change and record the method used to verify the new information.