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Effective Date: 


Note: This form is available only from Centralized Benefit Services staff. Call 2-1-1 or 1-877-541-7905 (after choosing a language, press 2) to request an application.


Updated: 4/2015


  • To serve as an application form for the Supplemental Nutrition Assistance Program Combined Application Project (SNAP-CAP).
  • To serve as an outreach application for initial certification and re-certifications of SNAP-CAP.
  • To establish a SNAP-CAP application file date.
  • To serve as a document for applicants to designate an authorized representative (AR).


When to Prepare

Supplemental Security Income (SSI) recipients meeting SNAP-CAP requirements complete one copy of the form when automatically outreached by the Texas Health and Human Services Commission (HHSC) state office.

The outreached individual or a designated AR may complete and sign the form. Applicants may use page 2 of the form to designate an AR.

HHSC staff must help the applicant with completing the form if the applicant requests help. The HHSC staff member must initial any entries the staff member makes on the form.

Number of Copies


Original only.


State office automatically mails an application to individuals potentially eligible for SNAP-CAP.

A SNAP-CAP application returned to a local eligibility determination office must be faxed to the non-expedited fax line at 1-877-447-2839 the same day it is received for task creation for the Centralized Benefit Services (CBS) unit.

Note: Form H1841 is used to apply for SNAP-CAP only.

Form Retention

See the Texas Works Manager's Guide for retention requirements.


Application for Assistance

Pages 1 and 2 are the actual application for assistance.

Voter Registration — Give Form H0025, Voter Registration Application, to individuals who indicate an interest in registering to vote and who meet the voting registration requirements. Authorized representatives or representative payees also may take Form H0025 to the individual to complete. Mail Form H0025 when the individual does not have a face-to-face interview or the individual reports a change of address by telephone or by mail. If requested, assist in the completion of Form H0025.

If the individual declines to register to vote during a face-to-face interview, ask the person to sign Form H1350, Opportunity to Register to Vote. Mail Form H1350 to an individual who did not have a face-to-face interview who declines the opportunity to register to vote, based on receipt of Form H0025.

Voter Registration Status — Check the appropriate box under Agency Use Only and sign.

Page 3 lists an overview of SNAP-CAP, information regarding who is eligible, benefit amounts, appeal information, and a number to call for more information or help.

Page 4 includes a Privacy Act statement and penalty information.