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Effective Date: 



Updated: 1/2011


  • To serve as a periodic review form for the Temporary Assistance for Needy Families (TANF) program for cases processed in the Texas Integrated Eligibility Redesign System (TIERS).
  • To serve as a recertification application for Supplemental Nutrition Assistance Program (SNAP) households in TIERS.
  • To serve as a renewal/review application for Medical Programs in TIERS.
  • To serve as an initial application for benefits if the household submits the renewal application after their case is denied in TIERS.
  • To serve as a screening document for SNAP clients who may be entitled to expedited service, in the event the form is used as an application.
  • To serve as a document for households to designate an authorized representative (AR).
  • To serve as a document for an AR's acknowledgement of an AR's responsibilities.
  • To serve as a screening document for advisors to make necessary referrals to other agencies.
  • To provide applicants and recipients the opportunity to register to vote.


When to Prepare

The household completes the form when reapplying for TANF, Medical Programs and SNAP.

If an applicant needs help completing the application packet, a volunteer or staff member must help. Anyone that helps to complete the application must initial the part completed, or sign the form showing that the assisting individual helped complete it as described in A-113, Application Assistance.


Form H1010-R is sent with Form H1830-R during the month before the last month of certification.

TANF and TANF Level Families Medicaid

Form H1010-R is sent with Form H1830-R during the two months before the review date.

Children's Medicaid

Form H1010-R is sent with Form H1830-R when the household has another Texas Works program up for renewal during the fourth month of a six-month certification or the 10th month of 12-month certification.


TIERS mails Form H1010-R, which is pre-populated with basic client information. The form is sent to all Texas Works households that are up for renewal, review or recertification along with Form H1830-R. The forms can only be reprinted upon request through the TIERS Correspondence functional area.

Clients may fax the form to 1-877-477-2839 or mail it to:

Health and Human Services Commission
P.O. Box 14700
Midland, TX 79711-4700

Form Retention

See the Texas Works Manager's Guide.

Detailed Instructions

The form is client-completed and self-explanatory. To evaluate specific answers, refer to policies in the Texas Works Handbook.

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

If the applicant or client declines to register to vote during an in-person interview, ask the client to sign Form H1350, Opportunity to Register to Vote. Mail Form H1350 to a client 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.