Human Services 1 0
Resume:
Application for benefits
Texas Health and Human Services Commission
H1010
Page 1
Your Texas Benefits: Form Please use dark ink. Please print. If you need more room, add pages. Fill in the circles like this
Mark the benefits anyone on your case is applying for:
● SNAP Food Benefits
TSAP Food Benefits
TANF Cash Help
for Families
Health-care benefits:
Children Adult caring for a Child
Adult not caring for a Child
Pregnant Woman
Section A
Your Facts
If you’re applying to
get SNAP food
benefits, the first
month’s amount will
be based on the date we
get pages 1 and 2.
Other benefits also are
based on when we get
pages 1 and 2.
If you send only
pages 1 and 2 now,
you will still need to
fill out the rest of the
application to get
benefits.
You have the right
to file this form
immediately if it has
your name, address,
and signature.
Person 1: contact person or head of household
Aaron
First name
Rockeem
Middle name
Belk
Last name
6 4 3 1 0 8 1 7 8
Social Security number
- - 0 8 1 7 1 9 8 9
Birth date (month/day/year)
/ /
4242 Wilshire Blvd
Mailing address
Dallas
City
Texas
State
75241
ZIP
Home phone
Cell or daytime phone
4242 Wilshire Blvd
Home address
Dallas
County
Dallas
City
Texas
State
75241
ZIP
You might be able to get SNAP food benefits the next work day if you:
• Are a migrant or seasonal farm worker,
• Have $100 or less in available cash and bank accounts and expect to earn less than
$150 this month, or
• Have costs for housing or utilities that are more than your cash, bank accounts and the income you expect for the month.
Answer them for everyone living in your home.
1. Is anyone in the home a migrant worker or a seasonal farm worker? Yes ● No 2. Does anyone in the home have money in the bank or cash? Yes ● No Amount 3. Does anyone in the home expect to receive money this month? (This includes money you get from jobs, child support, social security, and unemployment) Yes ● No Amount 4. Does anyone in the home pay costs for housing and utilities? (This includes rent, mortgage, water, gas, electric, sewage, trash, phone and property tax.) Yes ● No Amount Section B
SNAP Food
Benefits
This section is
only for people
applying for
SNAP food
benefits.
Find out how to
return your form:
See page 3.
I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not, I may be subject to criminal prosecution. Sign here (or have someone with the right to act for you sign) Date More on page 2
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 2
Is anyone in your home pregnant? Yes No If yes, who?
Number of
babies expected
Is this your first pregnancy? Yes No Due date / / What is the first and last name of the unborn child’s father? First name Last name
Pregnant
Women
This section is only
for people applying
for health-care
benefits.
Section C
Was anyone in your home pregnant during the last 12 months? Yes No If yes, who?
When did the pregnancy end?
/ /
Is anyone an active duty member of one of these military forces?
• U.S. Armed Forces
• National Guard
• Reserves
• State Military Forces Yes No If yes, who?
Military
Service
This section is only
for people applying
for health-care
benefits.
Section D
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 3
1. Most people applying for benefits must be interviewed. We often interview people on the phone.
It helps to know if any of the reasons below make it hard for you to get to a benefits office: Do any of the reasons above apply to you? 2. If you come to our office, will you need special help or equipment? 4. Will you need an interpreter? We can get one for you for free. If yes, mark the one you need:
• You live more than 30
miles from the closest
benefits office.
• You can’t get a ride.
• The weather is bad.
• You are sick.
• Your work or training
hours don’t allow you to
get to a benefits office
when it’s open.
• You can’t travel because
you are age 60 or older,
or you have a disability.
• You are a victim of
family violence.
• You take care of
someone in your home.
Interview
Help
If yes, what do you need?
Yes ● No
Yes ● No
Yes ● No
Spanish Vietnamese
American Sign Language Other:
Section E
3. What language do you want to speak during the interview? English Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 4
Your Texas Benefits: Form
Fill in the circles like this
Please use dark ink. Please print. If you need more room, add pages. Section F
Contacting
You
Person 1: Contact Person or Head of Household
Aaron
First name
Rockeem
Middle name
Belk
Last name
6 4 3 1 0 8 1 7 8
Social Security number
0 8 1 7 1 9 8 9
Birth date (month/day/year)
- - / /
*****.****@*****.***
Are you applying for benefits for yourself or a child? ● Yes No If yes, give your facts below:
Section G
Person 1
Mark the benefits
Person 1 is applying for:
● SNAP Food Benefits
TSAP Food Benefits
TANF Cash Help
for Families:
TANF
One-Time TANF
One-Time TANF for Relatives
Children
Health-care benefits for:
Adult Caring for a Child
Adult not caring for a Child
Pregnant Woman
Person 1
If you get money from Social
Security or railroad retirement,
list the number you have: Social Security claim number Railroad retirement number Married Single Divorced
Separated Widowed
Live in Texas? ● Yes No
Plan to stay in Texas? Yes No
Optional
Questions
● Male Female Hispanic or Latino? Yes ● No Mark one or more:
● Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Are you going to school? Yes ● No If yes, are you going full-time? Yes No Are you a U.S. citizen? If no, give facts below. ● Yes No Are you a refugee or legally admitted immigrant? Yes No If you have a sponsor, write your sponsor’s name Date you entered the U.S. (month/day/year)
/ /
Are you registered with the U.S.
Citizenship and Immigration Services? Yes No Immigrant registration number Women 15-44 years old who do not qualify for Medicaid or CHIP are automatically tested for Healthy Texas Women (HTW) eligibility. Check the box below if you waive HTW testing. I do not want to be tested for HTW
Veteran? ... Yes ● No
Return this completed form
by fax, mail, or in person:
Fax: 1-877-***-****
Mail: HHSC, PO Box 149024
Austin, TX 78714-9968
In person: Call 2-1-1 to find an HHSC
benefits office near you.
Use pages 4 and 5 for other
people applying for benefits.
If you need more pages, you can:
• Add a blank page and write in your facts.
OR
• Go to www.hhsc.state.tx.us to get an
extra page.
Click on “How to Get Help.”
Section H
People
Applying
for Benefits
Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 5
Hispanic or Latino? Mark one or more:
Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money from
Social Security or railroad
retirement, list the number here:
adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.
Citizenship and Immigration Services? ...
Questions
Optional
Person 2:
First name Middle name Last name
Social Security claim # Railroad retirement #
Married Single Divorced Live in Texas? Yes No
Separated Widowed
Male Female Yes No
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Yes No Yes No
Yes No
Yes No
Yes No Immigrant registration number
If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
/ /
Mark the benefits
Person is applying for:
TANF Cash Help
for Families :
Health-care benefits for:
SNAP Food Benefits
TSAP Food Benefits
TANF
One-Time TANF
One-Time TANF for Relatives
Children
Adult Caring for a Child
Adult not caring for a Child
Pregnant Woman
Social Security number Birth date (month/day/year)
- - / /
This person's relationship to you
Plan to stay in Texas? Yes No
Veteran? ... Yes No I do not want to be tested for HTW Hispanic or Latino? Mark one or more:
Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money from
Social Security or railroad
retirement, list the number here:
adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.
Citizenship and Immigration Services? ...
Questions
Optional
Person 3:
First name Middle name Last name
Social Security claim # Railroad retirement #
Married Single Divorced Live in Texas? Yes No
Separated Widowed
Male Female Yes No
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Yes No Yes No
Yes No
Yes No
Yes No Immigrant registration number
If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
/ /
Mark the benefits
Person is applying for:
TANF Cash Help
for Families :
Health-care benefits for:
SNAP Food Benefits
TSAP Food Benefits
TANF
One-Time TANF
One-Time TANF for Relatives
Children
Adult Caring for a Child
Adult not caring for a Child
Pregnant Woman
Social Security number Birth date (month/day/year)
- - / /
This person's relationship to you
Plan to stay in Texas? Yes No
Veteran? ... Yes No I do not want to be tested for HTW Section H
People
Applying
for Benefits
Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 6
Hispanic or Latino? Mark one or more:
Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money from
Social Security or railroad
retirement, list the number here:
adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.
Citizenship and Immigration Services? ...
Questions
Optional
Person 4:
First name Middle name Last name
Social Security claim # Railroad retirement #
Married Single Divorced Live in Texas? Yes No
Separated Widowed
Male Female Yes No
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Yes No Yes No
Yes No
Yes No
Yes No Immigrant registration number
If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
/ /
Mark the benefits
Person is applying for:
TANF Cash Help
for Families :
Health-care benefits for:
SNAP Food Benefits
TSAP Food Benefits
TANF
One-Time TANF
One-Time TANF for Relatives
Children
Adult Caring for a Child
Adult not caring for a Child
Pregnant Woman
Social Security number Birth date (month/day/year)
- - / /
This person's relationship to you
Plan to stay in Texas? Yes No
Veteran? ... Yes No I do not want to be tested for HTW Hispanic or Latino? Mark one or more:
Is this person going to school? If yes, is this person going full-time? Is this person a U.S. citizen? If no, give facts below. Is this person a refugee or legally admitted immigrant? If this person gets money from
Social Security or railroad
retirement, list the number here:
adult or child applying, spouse of person applying, or parent living with a child who is applying Is this person registered with the U.S.
Citizenship and Immigration Services? ...
Questions
Optional
Person 5:
First name Middle name Last name
Social Security claim # Railroad retirement #
Married Single Divorced Live in Texas? Yes No
Separated Widowed
Male Female Yes No
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Yes No Yes No
Yes No
Yes No
Yes No Immigrant registration number
If this person has a sponsor, write the sponsor’s name Date you entered the U.S. (month/day/year)
/ /
Mark the benefits
Person is applying for:
TANF Cash Help
for Families :
Health-care benefits for:
SNAP Food Benefits
TSAP Food Benefits
TANF
One-Time TANF
One-Time TANF for Relatives
Children
Adult Caring for a Child
Adult not caring for a Child
Pregnant Woman
Social Security number Birth date (month/day/year)
- - / /
This person's relationship to you
Plan to stay in Texas? Yes No
Veteran? ... Yes No I do not want to be tested for HTW Section I
More Facts
About Children
Age 18 or
Younger
This section is
only for children
applying for TANF
cash help for
families.
Time Saving Tip
You only need to give
facts for each father
and mother one time.
If a child has the same
mother or father as
another child, you can
write something like
“same as 1st child”
where the parent’s
name would go.
Are you afraid that
giving facts about the
child’s other parent
might put you or your
children in danger?
You might not have to
help or cooperate with
the Office of Attorney
General to collect child
or medical support if you
are afraid. You can ask
not to give these facts by:
• Telling your benefits
advisor (or designated
representative) reasons
why this might put
you or your children
in danger.
• Signing the Good
Cause request form.
(Your benefits advisor
has this form.)
Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 7
1st child's name:
Father is:
Were these parents ever married to each other? Mother is:
MOTHER FATHER
Father's birth date
/ /
Father's first and last name
Father's Social Security number Father's phone
Father's mailing address City State ZIP
Employer
In home Out of home Deceased Employer
Mother's first and last name Mother's maiden name
Mother's Social Security number Mother's birth date Mother's mailing address City State
Mother's phone
ZIP
In home Out of home Deceased
Yes No
- -
- - / /
2nd child's name:
Father is:
Were these parents ever married to each other? Mother is:
MOTHER FATHER
Father's birth date
/ /
Father's first and last name
Father's Social Security number Father's phone
Father's mailing address City State ZIP
Employer
In home Out of home Deceased Employer
Mother's first and last name Mother's maiden name
Mother's Social Security number Mother's birth date Mother's mailing address City State
Mother's phone
ZIP
In home Out of home Deceased
Yes No
- -
- - / /
Section I
More Facts
About Children
Age 18 or
Younger
(continued)
Are you afraid
that giving us facts
about someone
could cause harm
(physical or
emotional) to you
or your child?
If yes, you might
not have to give us
facts about that
person. You might
be able to get the
"Family Violence
Exemption."
Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 8
3rd child's name:
Father is:
Were these parents ever married to each other? Mother is:
MOTHER FATHER
Father's birth date
/ /
Father's first and last name
Father's Social Security number Father's phone
Father's mailing address City State ZIP
Employer
In home Out of home Deceased Employer
Mother's first and last name Mother's maiden name
Mother's Social Security number Mother's birth date Mother's mailing address City State
Mother's phone
ZIP
In home Out of home Deceased
Yes No
- -
- - / /
4th child's name:
Father is:
Were these parents ever married to each other? Mother is:
MOTHER FATHER
Father's birth date
/ /
Father's first and last name
Father's Social Security number Father's phone
Father's mailing address City State ZIP
Employer
In home Out of home Deceased Employer
Mother's first and last name Mother's maiden name
Mother's Social Security number Mother's birth date Mother's mailing address City State
Mother's phone
ZIP
In home Out of home Deceased
Yes No
- -
- - / /
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 9
Other people in the home
These people live in my home, but they don’t want to apply for benefits.
(Parents living with a child age 18 or younger who is applying or a spouse of a person applying should not be listed here they should fill out a box in Section H.) List the birth date only if the person is your relative. Name Relationship to you Birth date (if relative)
Name Relationship to you Birth date (if relative)
Name Relationship to you Birth date (if relative)
Other People
in the Home
Section J
Information about people applying for benefits
1. Does a child applying for health care travel with a family member who is a migrant farm worker? Yes ● No
2. Is a child in the Children with Special Health Care Needs program? Yes No If yes, who?
3. Is anyone an American Indian or Native Alaskan? Yes No If yes, who? What tribe?
Yes No This means a person is: (1) not living with a relative,
(2) age 18 or younger, and (3) a refugee.
4. Is anyone an unaccompanied refugee minor?
If yes, who?
Help Us Serve
You Better
This section is
only for people
applying for
health-care benefits.
Section K
These questions will
not be used to decide
if your family can
get benefits.
Other Facts
1. Does anyone have a disability? Yes ● No If yes, who?
2. Is anyone getting TANF cash help for families, SNAP food benefits or health-care benefits from another state? Yes ● No If yes, who? Which state? When did that person last get benefits? Other Facts
Section L
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 10
3. Has anyone been convicted of a felony that:
(1) took place after August 22, 1996, and (2) involved illegal drugs? Yes ● No If yes, who?
4. Is anyone living in a place of care such as:
•A homeless shelter
•A family violence shelter
•A drug treatment center
•A group home ● Yes No Aaron Rockeem Belk
If yes, who?
Homeless or temporary living
situation for 90 days or less? ● Yes No
5. When people break program rules, they are sometimes "disqualified" from getting benefits. People who are disqualified are sent a letter and told they can't get TANF cash help for families or SNAP food benefits.
Is anyone living with you disqualified from getting TANF cash help for families or SNAP food benefits anywhere in the United States? Yes ● No 6. Was anyone in foster care when they were age 18 or older? Yes ● No If yes, who? In which state?
Other Facts
(continued)
Answer 3, 4 and 5
only if anyone
is applying for
TANF cash help for
families or SNAP
food benefits.
Section L
Other health insurance
Does anyone have health insurance other than Medicare, Medicaid, or CHIP? If yes, give facts below.
Yes ● No
Name of insured person (first, middle, last) Insurance company Policy number Coverage start date Coverage end date Type of coverage How much is your premium? Who pays the premium? Reason coverage ended Amount you pay each month to cover your children on this insurance
Section M
Medical Facts
This section is
only for people
applying for TANF
cash help for
families or
health-care benefits.
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 11
Name of insured person (first, middle, last) Insurance company Policy number Coverage start date Coverage end date Type of coverage How much is your premium? Who pays the premium? Reason coverage ended Amount you pay each month to cover your children on this insurance.
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 12
Medical bills from the past 3 months
If anyone on your case can't pay their medical bills, Medicaid might pay them.
•The bills must be for services they got in the past 3 months.
•You need to show proof of money you get (income) for the month(s) they got services. Does anyone applying for benefits have medical bills for services they got in the past 3 months? Yes ● No if yes, who? (first, middle, last)
Medical Facts
(continued)
This section is
only for people
applying for TANF
cash help for
families or
health-care benefits.
Section M
Vehicles
•car •truck •boat •motorcycle •other Yes No Does anyone own or is anyone paying for a:
If yes, give facts below.
Name of owner (first, middle, last) Make/Model
Name of co-owner if also owned by someone outside the home Money still owed on vehicle
VEHICLE 1
Year
Vehicle is used for a person with a disability.
Things
Anyone is
Paying for
or Owns
Skip this section
if you are applying
only for health-care
benefits.
Section N
If you need
more room, add
more pages with
the same facts.
Name of owner (first, middle, last) Make/Model
Name of co-owner if also owned by someone outside the home Money still owed on vehicle
VEHICLE 2
Year
Vehicle is used for a person with a disability.
Name of owner (first, middle, last) Make/Model
Name of co-owner if also owned by someone outside the home Money still owed on vehicle
VEHICLE 3
Year
Vehicle is used for a person with a disability.
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 13
Things anyone is paying for or owns
Yes ● No
• cash • bank accounts • homes and other property • insurance policies • stocks We need to know about items anyone owns or is paying for, such as: Does anyone own or is anyone paying for these types of items? If yes, give facts below.
Item Account number
Names on account or deeds (include co-owners)
Value
Name and address of bank or business (to contact about item) Item 1
Section N
Skip this section
if you are applying
only for health-care
benefits.
Things
Anyone is
Paying for
or Owns
(continued)
Account number
Names on account or deeds (include co-owners)
Value
Name and address of bank or business (to contact about item) Item 2
Item
Account number
Names on account or deeds (include co-owners)
Value
Name and address of bank or business (to contact about item) Item 3
Item
Money anyone might get from other programs
If yes, mark the program anyone is waiting to hear from. Is anyone waiting for an answer on an application for one of the programs listed below? Yes ● No Social Security (RSDI) Supplemental Security Income (SSI) Other disability Unemployment compensation benefits Money
Coming into
the Home
Section O
Name of person waiting for an answer Program Name
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 14
Money from jobs or training
(a) working for someone else (b) training, or (c) working for themselves? Yes ● No Did anyone get money in the past 3 months from:
If yes, give facts below.
Name of person who got money from a job
If no, list the person or place that paid the money. Hours worked Amount paid
Job 1
before taxes and
deductions are taken out
Start date Last payment date (month/year)
How often are you paid?
daily
once a week
every 2 weeks other:
once a month
twice a month
Is this person still working at this job or in training? Yes No Was this person working for themselves? Yes No Your job may take money out of your check before taxes. These are pretax contributions. They may be for retirement savings, medical insurance premiums, a health savings account, dependent care expenses, commuter expenses or life insurance premiums. Total pretax contributions per pay period How often is it contributed Date contributed Money
Coming into
the Home
(continued)
Section O
Name of person who got money from a job Hours worked If no, list the person or place that paid the money. Amount paid
Job 2
before taxes and
deductions are taken out
Start date Last payment date (month/year)
How often are you paid?
daily
once a week
every 2 weeks other:
once a month
twice a month
Is this person still working at this job or in training? Yes No Was this person working for themselves? Yes No Total pretax contributions per pay period How often is it contributed Date contributed Section O
Money
Coming into
the Home
(continued)
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 15
Name of person who got money from a job Hours worked If no, list the person or place that paid the money. Amount paid
Job 3
before taxes and
deductions are taken out
Start date Last payment date (month/year)
How often are you paid?
daily
once a week
every 2 weeks other:
once a month
twice a month
Is this person still working at this job or in training? Yes No Was this person working for themselves? Yes No Total pretax contributions per pay period How often is it contributed Date contributed 6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 16
Other Money
Does anyone get, or expect to get, any of the types of money listed below? Yes ● No If yes mark other types of money anyone gets or might get soon. Social Security.
Supplemental Security
Income (SSI).
Retirement benefits.
Veterans benefits.
Child support anyone gets.
Cash or gifts.
Payments after being hurt at
work (worker's compensation).
Payments after losing a job
(unemployment compensation).
Alimony/Spousal Support
Interest or dividends.
Payments from private insurance
Loans paid to anyone
on your case.
Payments to help with utilities
Rent paid to you.
Other
If anyone gets, or expects to get, any of these types of money, give the facts below. Money
Coming into
the Home
(continued)
Section O
MONEY TYPE 1
Type of money (item you marked above) Amount you get paid Last payment date (month/year) Name of person getting this money (if child support, list child's name) Person, company, or agency paying the money
How often are you paid?
daily
once a week
every 2 weeks
other:
once a month
twice a month
MONEY TYPE 2
Type of money (item you marked above) Amount you get paid Last payment date (month/year) Name of person getting this money (if child support, list child's name) Person, company, or agency paying the money
How often are you paid?
daily
once a week
every 2 weeks
other:
once a month
twice a month
MONEY TYPE 3
Type of money (item you marked above) Amount you get paid Last payment date (month/year) Name of person getting this money (if child support, list child's name) Person, company, or agency paying the money
How often are you paid?
daily
once a week
every 2 weeks
other:
once a month
twice a month
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 17
Housing costs
Or for a home they plan to return to? 1. Does anyone pay any of the costs listed below for the home they are living in? Yes ● No
If yes, mark the costs
they have and list
the amount:
Natural gas/propane
Phone
Water and sewer
Tax on home
Rent or home payment
Electricity
Home insurance
Other
2. Does anyone not on your case and not living in your home help pay your housing costs? Yes ● No Housing Costs
This section is only
for people applying
for SNAP food benefits.
Section P
Costs to take care of others
Does anyone have costs
to take care of others?
If yes, give facts below.
Yes No
•Child care costs so someone can work,
look for work, go to training, or go to school.
Examples:
•Child support payments, medical bills, and health insurance you pay for a child living outside the home.
•Costs for people with disabilities or adults
who need help caring for themselves.
•Alimony payments.
Costs to
Take Care
of Others
Section Q
Type of cost
COST 1
Person or company that gets the money (name, address, and phone number) Who pays the cost?
First name of person who gets care or support
Amount paid
How often paid?
daily
once a week
every 2 weeks
other:
once a month
twice a month
Date last paid
For court ordered child support
list child who gets support
(provide copy of court order)
Type of cost
COST 2
Person or company that gets the money (name, address, and phone number) Who pays the cost?
First name of person who gets care or support
Amount paid
How often paid?
daily
once a week
every 2 weeks
other:
once a month
twice a month
Date last paid
For court ordered child support
list child who gets support
(provide copy of court order)
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 18
Medical costs
Does anyone age 60 or older, or anyone with a disability, pay medical costs Yes No If yes, mark the type of costs they pay:
Doctor Hospital Medicine Health insurance
Medical Costs
This section is
only for people
applying for SNAP
food benefits or
health-care
benefits.
Section R
Agency Use Only: Voter Registration Status
Already registered
Client to mail
Client declined
Mailed to client
Agency transmitted
Other Agency staff signature
6 4 3 1 0 8 1 7 8
Social security number:
- - Application for benefits
Texas Health and Human Services Commission
H1010
04/2024
Page 19
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