- To serve as a recertification application for Texas Simplified Application Households (TSAP) households 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 TSAP.
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 person helped complete it.
Form H0011-R is sent with Form H1830-R, Texas Works Renewal Notice, during the month before the last month of certification.
TIERS mails Form H0011-R, which is pre-populated with basic client information. The form is sent to all TSAP 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 877-477-2839 or mail it to:
Texas Health and Human Services Commission
P.O. Box 14700
Midland, TX 79711-4700
The form is client-completed. To evaluate specific answers, refer to policies in the Texas Works Handbook.
Signing up to vote — 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 phone 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.