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Effective Date: 



Updated: 7/2015


To advise applicants and recipients of the opportunity to:

  • register to vote,
  • decline to register to vote, or
  • change their voter registration information.


When to Prepare

The individual does not need to sign Form H1350 if the case record verifies the individual does not meet U.S. citizenship or age requirements and the individual acknowledges the noncitizen status, or if the individual has a face-to-face interview that includes voter registration information on the application, renewal/recertification or change report form.

Ask the individual to sign Form H1350 at application, renewal/recertification or when reporting a change of address if the individual indicates he does not wish to register to vote or change his voter registration information.

Mail Form H1350 to an individual who did not have a face-to-face interview if the individual notifies the local office of the decision to decline the opportunity to register to vote, based on the receipt of Form H0025, Voter Registration Application.

Number of Copies

Original only. Mail the individual a copy for signature and request that the individual return the form to HHSC.


File the completed Form H1350 under legal.

In the Texas Integrated Eligibility Redesign System (TIERS), send the form to the Document Processing Center (DPC) for imaging.

Form Retention

Keep Form H1350 in the case record for 22 months.

Detailed Instructions

If the individual answers No to the question about applying to register to vote, ask the individual to sign and date the declaration statement on Form H1350.

If the individual answers Yes to the question about applying to register to vote, provide the individual with Form H0025.

Complete the Agency Use Only section to indicate the actions taken to provide the individual with an opportunity to register to vote:

  • If the individual answers Yes to the question and a completed Form H0025 will be transmitted to the county voter registrar, check one of the following options:
    • Agency Transmittal
    • Individual to Mail
    • Mailed to Individual
  • If the individual answers No to the question, check one of the following options:
    • Individual Declined (to register to vote, or to complete and sign Form H1350)
    • Other (documentation is required)

Staff sign and date Form H1350.