Form H0011R, Texas Simplified Application Project (TSAP) for SNAP Food Benefits Renewal

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Effective Date: 10/2023


Updated: 7/2024


To provide applicants and recipients the opportunity to register to vote and serve as a:

  • Recertification application for Texas Simplified Application Households (TSAP) households in TIERS.
  • New application for benefits if the household submits the renewal application after their case is denied in TIERS.
  • Screening document for SNAP clients who may be entitled to expedited service, in the event the form is used as an application.
  • Document for households to designate an authorized representative (AR).
  • Document for an AR's acknowledgement of their responsibilities as an AR.
  • Screening document for staff to make necessary referrals to other agencies.


When to Prepare

The household completes the form when reapplying for TSAP.

If a person needs help completing the application packet, a volunteer or staff member must help. Anyone who helps complete the application must initial the part they helped complete or sign the form to show they helped complete it.

Form H0011-R is sent with Form H1830-R, Texas Works Renewal Notice (PDF), during the month before the last month of certification.

Number of Copies

Save a copy in the electronic case record. Upon request provide the household with a copy or a Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change (PDF).


TIERS pre-populates the renewal form with basic client information. The form is sent to all TSAP households that are due for renewal, review, or recertification along with Form H1830-R. The forms can only be reprinted upon request.

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

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

Detailed Instructions

The client completes the form. To evaluate specific answers, refer to policies in the Texas Works Handbook.

Signing up to vote – Give Form H0025, Voter Registration Application (PDF), 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 phone or by mail. Help in the completion of Form H0025 if requested.

If the applicant or client declines to register to vote during a face-to-face interview, ask the client to sign Form H1350, Opportunity to Register to Vote (PDF). 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.