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To obtain a written statement from an applicant or client that the household:
- has not previously received benefits that month; or
- had some food destroyed that was purchased with SNAP benefits.
To provide a record of a person's statement for use if HHSC discovers perjury or an intentional program violation.
When to Prepare
Complete Form H1855 before:
- replacing food purchased with SNAP benefits that were reported destroyed; or
- issuing priority benefits when TIERS is unavailable.
Number of Copies
Prepare an original and one copy.
File the agency copy in the case record. Give the client copy to the person.
Staff complete Form H1855 according to information supplied by the household.
Ensure that the person reads the form and understands what they are signing. The head of the household, spouse, or responsible household member must sign Form H1855 in ink in the presence of the witnessing worker.
Exception: If the person is unable to come to the office to complete Form H1855, staff must:
- schedule a home visit;
- allow the authorized representative (AR) to take the form to the person and return it to the office; or
- mail the form to the person with a postage paid return envelope.
Note: Mail Form H1855 only if the person:
- is aged, handicapped, or lives more than 30 miles from the office; and
- cannot appoint an AR to bring the form to the office.
Allow the AR to sign Form H1855 only if:
- the applicant is interviewed by phone; or
- the AR completes the interview for the applicant.
Certifying Office — Enter the name of the certifying office to which the case is assigned.
Case Name — Enter the name of the head of the household as listed in the case record.
Case No. — Enter the households SNAP case number.
Current Address — Enter the household's current mailing address.
Complete the following when replacing benefits:
Date Reported — Enter the date the client requested the replacement.
Date Received — Enter the date the local office received the signed form.
Old Address — Enter the client's old address, if different from the current address.
Benefit Month and Year and Allotment Amount — The month and year for which the benefit was issued and the amount of the allotment.
Original Issuance No. and Original Issue Date — If applicable, the serial number and issue date of the issuance used to purchase food reported as destroyed.
Ensure that the month shown in the identifying information at the top of the form and the month shown in the lower section are the same when providing replacement benefits.