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 provide the Customer Care Center- Electronic Disqualified Recipient System (CCC-eDRS) staff with disqualification information from Data Broker regarding clients who have active intentional program violations (IPVs) in other states, so they can obtain secondary verification if applicable.
- To provide the Office of Inspector General (OIG) with disqualification information about clients who have active IPVs imposed in other states, so they can enter the IPV data into the Texas Integrated Eligibility Redesign System (TIERS).
When to Prepare
Advisors complete this form when it is discovered that the applicant/recipient has an active IPV in another state that must be reported to OIG for data entry in TIERS.
Number of Copies
The advisor completes an original and has it imaged for the case record.
If secondary verification is:
- not required, advisors complete Part I and email attached Form H1856 using secure Voltage to CCC-eDRS staff at HHSC OES CCC IC. CCC-eDRS staff review the form for accuracy, correct as needed and send it to CDU at firstname.lastname@example.org.
- required, advisors email attached Form H1856 to CCC-eDRS staff using secure Voltage at HHSC OES CCC IC. CCC-eDRS staff complete Part II and email the attached Form H1856 to CDU at email@example.com.
See retention requirements in the Texas Works Manager's Guide.
Part I: To be completed by the Texas Works Advisor
The Texas Works advisor completes Part I of this form after obtaining the disqualification information from Data Broker.
Expedited — Check the box to indicate whether this involves an expedited application.
SNAP EDG Number — Enter the SNAP EDG number assigned to the case.
Originating State Where IPV Occurred — Enter the name of the state where the individual originally was disqualified for the IPV.
Disqualified Individual's Name — Enter the name of the disqualified individual.
Disqualified Individual's Date of Birth — Enter the disqualified individual’s date of birth (mmddyyyy).
Social Security Number — Enter the disqualified individual’s Social Security number.
Client Number in Originating State — Enter the client number assigned to the disqualified individual in the originating state.
Decision Date — Enter the decision date displayed in Data Broker.
Number of Disqualification Months — Identify if the disqualification is for lifetime, or enter the number of months the individual is disqualified.
Disqualification Dates — Enter the date the disqualification period began and the date it is scheduled to end.
Offense Occurrence — Enter the offense occurrence (first, second or third). The out-of-state contact person provides this information.
Offense Description — Enter the description as it appears in Data Broker.
Client Statement — Check the box to indicate if the client/household disputes the IPV data or if unable to contact the client/household.
Standard/Non-Standard Penalty — Indicate if Data Broker reports the penalty period as non-standard.
Non-Standard Penalty Description — Enter the description of the non-standard penalty period, if applicable, as it appears in Data Broker.
Additional Comments — This box is available for the advisor to enter any additional comments the advisor determines may be needed, such as any statements the client offers when disputing the IPV data.
Advisor Name, Area Code and Phone Number — Self-explanatory.
Date Completed — Self-explanatory.
Part II: To be completed by CCC-eDRS Advisor
CCC-eDRS staff will complete this information when secondary verification is needed. Once Part II is completed, CCC-eDRS staff will email this form using secure Voltage to OIG-CDU at CDU@hhsc.state.tx.us. If secondary verification is not required, CCC-eDRS staff will complete the last line of Part II with name, date completed and phone number.
Out-of-State Contact Person’s Name — Enter the full name of the person who was contacted to obtain the disqualification information.
Contact’s Area Code and Phone Number — Enter the phone number of the out-of-state contact person.
Contact’s Mailing Address — Enter the out-of-state contact person’s mailing address.
Contact’s Email Address — Enter the out-of-state contact person’s email address.
Date Verified by Out-of-State Contact — Self-explanatory.
Out-of-State IPV Documents — Indicate whether any out-of-state IPV documents were obtained and, if so, what type of documents.
Additional Comments — This box is available for the CCC-eDRS advisor to enter any additional comments the advisor determines may be needed, such as any additional explanations provided by the out-of-state contact.
CCC-eDRS Advisor Name, Area Code and Phone Number — Self-explanatory.
Date Completed — Self-explanatory.