Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.

Effective Date: 



Updated: 9/2010


This form is used to:

  • Record the applicant's basic essential needs for TLC;
  • Provide the estimated amounts for items and services; and
  • Authorize the TLC provider to purchase items and services.


Number of Copies

Complete the original form and make two copies.


The original form is sent to:

HHS State Office
P. O. Box 149030
Austin, TX 78714-9030

One copy is given to the applicant and one copy is filed in the applicant's case folder.

Form Retention

The provider agency must maintain all records pertaining to the services provided to individuals in the Medicaid program for at least five years from the date the services were provided. If any litigation or claim involving these records is still ongoing at the conclusion of five years, the provider agency must maintain the records until all litigation or claims are resolved.

Detailed Instructions

Applicant Information

Enter the applicant's name and other information requested.

Money Follows the Person Demonstration

Check appropriate response to the question.

Authorized Representative Information

Complete this section only if the applicant's authorized representative or legal guardian is completing this application on behalf of the applicant.

Information on Person Assisting the Applicant with the Application

Complete this section only if the applicant receives assistance completing this application from another person.

Temporary Rental Assistance

The applicant must apply for subsidized housing in order to receive this assistance, which will be included in the $2,500 TLC maximum benefit amount.

Source of Ongoing Services

Identify the accepted ongoing community-based service and provide all information requested in the blocks provided.

The applicant must be accepted for services in at least one of these community-based programs to receive TLC benefits.

Shared Household Information

Check appropriate responses to each question.

Income and Resources

List all expected monthly income, both earned and unearned.

List all resources (for example, cash, stocks, property, vehicles, etc.), and describe which, if any, are available to help the applicant move from the facility.

Community Services and Assistance

Check all resources that were utilized prior to applying for TLC benefits.

Projected Living Expenses

List all projected monthly living expenses and any balances owed.

The applicant must provide any other information that explains how he or she will be able to live in the community after the TLC funds are spent.

Residence Relocation Type

Check the type of residence the individual has chosen.

Services Requested

List all services (and estimated costs) to be paid with TLC funds (for example, rent deposit, utility deposits, moving expenses, etc.).


Review this list of agreements with the applicant before having applicant sign the application.


The applicant signs and dates only if he/she agrees to the statements made in the Agreements section. If the applicant is unable to sign, two witnesses must sign and date to verify applicant's mark.

Signature — Authorized Representative

If the applicant is unable to sign or make his or her mark, have the authorized representative sign and date on behalf of the applicant. An authorized representative is an individual who does not necessarily have legal guardianship or power of attorney, but is selected by the applicant to serve as agent or responsible party for TLC purposes.

HHS State Office Use Only

To be completed by HHS state office.

Complex Needs of Individual

Check all that apply to the applicant.

Explanation of Complex Needs

Complete this section to describe the detail(s) of the applicant's complex need(s).