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Effective Date: 




Updated: 4/2003



To obtain a written statement from an applicant/client that his household

  • has not previously received benefits that month, or
  • had some food destroyed that was purchased with food stamp benefits.

To provide a record of a client's statement for use if HHSC discovers perjury or an intentional program violation.



When to Prepare

Complete Form H1855 before

  • replacing food purchased with food stamp benefits that was reported destroyed; or
  • issuing benefits via the Administrative Terminal Application (ATA).

Number of Copies

Prepare an original and one copy.


File the agency copy in the case record. Give the client copy to the client.

Form Retention

See the Texas Works Manager's Guide.


Detailed Instructions

Staff complete Form H1855 according to information supplied by the household.

Ensure that the client reads the form and understands what he is signing. The head of the household, spouse, or responsible household member must sign Form H1855 in ink in the presence of the witnessing worker.

Exception: If the client is unable to come to the office to complete Form H1855, staff must

  • schedule a home visit,
  • allow the A/R to take the form to the client and return it to the office, or
  • mail the form to the client with a postage paid return envelope.

Note: Mail Form H1855 only if the client

  • is aged, handicapped, or lives more than 30 miles from the office, and
  • cannot appoint an A/R to bring the form to the office.

Allow the A/R to sign Form H1855 only if

  • the applicant is interviewed by phone, or
  • the A/R completes the interview for the applicant.

Certifying Office — Enter the name of the certifying office to which the case is assigned.

Case Name — Enter the name of the head of the household as listed in the case record.

Food Stamp Case No. — Enter the households's food stamp case number.

Current Address — Enter the household's current mailing address.

Complete the following when replacing benefits:

Date Reported — Enter the date the client requested the replacement.

Date Received — Enter the date the local office received the signed form.

Old Address — Enter the client's old address, if different from the current address.

Benefit Month and Year/Amount of Allotment — The month and year for which the benefit was issued and the amount of the allotment.

Original Issuance No./Original Issue Date — If applicable, the serial number and issue date of the issuance used to purchase food reported as destroyed. This data is available on SAVERR inquiry.

Ensure that the month shown in the identifying information at the top of the form and the month shown in the lower section are the same when providing replacement benefits.