Human Services Your Income
Resume:
Form ****
You are getting this packet because either: (1) you applied for benefits, (2) you reported a change to your case, or (3) we must check your income to see if you can still get benefits. Inside this packet you will find:
You also might find other forms you can fill out and send to us. A list of the items we need from you.
A pre-paid envelope.
Terrance Mays
APT 321
9700 Leawood BLVD
Houston TX 77099-2657
If you have a hearing or speech disability,
call 7-1-1 or any relay service.
Mail: Texas Health and Human Services
Commission
PO Box 149024
Austin Texas 78714-9024
Fax:
Call 2-1-1
or for out of the state callers,
call 1-877-***-****
Need Help?
10/02/2024
Case Number: 103*******
To find out if you can get or keep getting benefits, we need more facts from you:
·
·
Send us the items by 10/14/2024
If you need help, call us at 2-1-1 or 877-***-****. After you pick a language, press 2. We can take your call Monday to Friday, 8 a.m. to 6 p.m. Central Time.
If you don't send us your items by this date,
you might not get benefits or your benefits might end. You still need to send us the items by this due date. For help or questions about your Lone Star Card account, call 1-800-***-**** (7EBT). There are 4 ways to send us the items we need:
Pick one of these ways to send the items back to us: Mail: Mail this letter and the items we need in the pre-paid envelope that came in this packet. Fax: Fax this letter and the items we need to 1-877-***-****.
·
· YourTexasBenefits.com: You can upload your items online. Don't forget:
Put your case number on everything you send us.
· Your Texas Benefits Mobile App: You can upload your items using the mobile app. The app is free to download in the Google Play and Apple iTunes stores.
·
·
· If you send us a letter or statement showing proof of facts we need, make sure the person who writes it includes:
(1) their name, (2) their address, (3) their phone number, (4) the date they wrote it, and (5) their signature. Form 1020
12/2022
Page 2 of 4
T-01020-0818176332
Benefit programs affected and due date:
Program EDG number Due date
For Food Stamp benefits: 692******-**/31/24
If you're afraid that giving us facts about someone could cause harm (physical or emotional) to you or your child:
If you're applying for or renewing Medicaid or CHIP benefits, you might not need to give us facts about that person. You might be able to get the "Family Violence Exemption." Let us know if you're afraid to give facts about someone:
· Phone: Call 2-1-1 or 1-877-***-**** (after picking a language, press 2).
· Mail: TEXAS HEALTH AND HUMAN SERVICES COMMISSION,P O Box 149024, Austin, Texas 78714-9024
· In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 or 1-877-***-**** (after picking a language, press 1).
· Fax: 1-877-***-****.
Form 1020-A Page 3 of 4
12/2022 T-01020-0818176332
LIST OF INFORMATION NEEDED AND/OR ACTION REQUIRED: Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof Terrance Mays Food Stamps Provide verification of all money you earn from any source. XL PARTS LLC
Contact the Employer
Data Broker
Employer.
Form 1028 Employment Verification
Form 2583 Choices Information Transmittal
Recent checks, stubs, or earnings statements.
TWC inquiry
Workshop or State School reimbursement officer
Form 1020B
12/2022
Page 4 of 4
T-01020-0818176332
Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024
Case Number: 103*******
The enclosed Missing Information form (Form 1020) includes a list of documents you need to send to us so we can determine your eligibility for services. See page 1 to find out how to send us your forms.
El formulario adjunto de información faltante (Formulario 1020) incluye una lista de documentos que usted necesita enviarnos para que podamos determiner si usted reúne los requisitos para los servicios. Vea la página 1 para saber cómo enviarnos sus documentos. T-01028-0818176332
10/02/2024
Case number:
Date:
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027
Need help? Call 2-1-1 or
Fax: 1-877-***-****
Mail: TEXAS HEALTH AND HUMAN SERVICES
COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027
If you are deaf, hard of hearing, or speech
impaired, call 7-1-1 or 1-800-***-****.
All numbers are free to call.
H1028
03/2021
Page 1
Note to Terrance Mays :
This form is for your employer. They need to fill out the form and return it by allow HHSC to give my Social Security number (SSN) to the employer listed on this form. My SSN can be used to get facts about my employment. I also allow the employer listed on this form to give facts asked on this form to HHSC. Sign here Date
10/14/2024
Terrance Mays
. You must agree to let them give facts about you. Fill out and sign this agreement:
I, (print your name)
Employer -- your help is needed:
We need proof that the following person is or was your employee. Employee or former employee Social Security number Terrance Mays
10/14/2024
Some employers might get tax refunds or tax credits for hiring people who get certain state benefits. To learn more, go to TexasWorkforce.org/wotc or email the Texas Workforce Commission at ****@***.*****.**.**. Employer -- please follow these steps:
This person lives in a home in which someone is applying for state benefits. We need to know the amount of money this person makes or made from this job.
1. Please fill out the “Proof of Employment” form on the next page. 2. If a question doesn't apply, mark it with "N/A." 3. Return the form by
To send this back to us, you can either: (a) give it to the employee listed above,
(b) mail it in the pre-paid envelope, or (c) fax it to 1-877-***-****. TERRANCE MAYS
APT 321
9700 LEAWOOD BLVD
HOUSTON TX 77099-2657
T-01028-0818176332
Proof of Employment Texas Health and Human Services Commission To be filled out by the employer Case number : 103******* 2. Company or employer address - street, city, state, ZIP: 3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP: 5. Is or was this person your employee?
If no: Stop here - sign and date the bottom of this form and return it. If yes: Answer all the questions below. If a question doesn't apply, write "N/A." XL PARTS LLC
Yes No
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply): Full Time Part time Permanent Temporary 10. Average hours per pay period:
11. Rate of pay: $ per: Hour Day Week Month Job
12. How often paid:
13. Does or did this person get overtime pay?
15. Is or was this person on leave without pay?
14. FICA or FIT withheld?
Daily Once a week Every 2 weeks
Twice a month Once a month Other:
Yes - often Yes - rarely No - never
Yes No
Yes No
If yes: Start date of leave: End date of leave:
16. Does this person have a profit sharing or pension plan? Yes No If yes: What is the current value? $
17. Does your company offer health insurance? Yes No If yes: This person is: Not enrolled Enrolled with family members Enrolled for self only If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months? Yes No If yes: Explain what will change:
19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts): Date pay
period ended
Date
received
Actual
hours
Gross pay amount
(before taxes taken out)
Other pay(include tips,
commissions and bonuses)
EITC Advance
amount
Total Pretax
Contributions
20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay: 21. Does this person still work for you? Yes No
If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $ Employer - read, sign, and date:
I confirm that this information is true and correct to the best of my knowledge: Employer -sign here Date Title Phone number
1. Company or employer name:
H1028
03/2021
Page 2
Contact this candidate