Form H0025, HHSC Application for Voter Registration

Instructions for Opening a Form

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Effective Date
01/2022
h0025.pdf (305.56 KB)
h0025-s.pdf (317.95 KB)

Note: Regional offices may obtain bulk supplies of this form through the Pinnacle forms and print product ordering system.

Instructions

Updated: 1/2022

Purpose

To provide applicants and recipients of Community Care Services Eligibility (CCSE), Long-Term Care Services, Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Medicaid the opportunity to register to vote and to update voter registration information.

Procedure

When to Prepare

Give Form H0025 to clients who indicate an interest in registering to vote. Authorized representatives or representative payees may also receive and complete Form H0025 for the client.

Mail Form H0025 when a face-to-face interview is not conducted, or a change of address is received in the mail on an agency approved change of address form.

If requested, assist in the completion of the Form H0025.

Number of Copies

Original only.

Transmittal

Within five calendar days of receipt of a completed Form H0025, mail or deliver to the voter registrar of the county where the HHSC office is located.

Form Retention

None.

Detailed Instructions

Entries on Form H0025 should be printed in ink.

  1. These Questions Must Be Completed… — Check one of the boxes to specify the purpose of the application. 

    Are you a United States citizen? — Select “Yes” or “No” to indicate if the person applying is a US citizen. 

    Will you be eighteen (18) years of age...? — Select “Yes” or “No” to indicate if the person applying will be eighteen years of age on or before the next upcoming election. 

    Are you interested in serving as an election worker? — Select “Yes” or “No” to indicate if the person applying is interested in serving as an election worker. 
     
  2. Name — Include the full Last Name and suffix (if any), full First Name, Middle Initial (if any), and former name (if any).
     
  3. Residence Address — Include street address, city, state, and ZIP. If there is no street address, give a description of the location where client lives.
     
  4. Mailing Address — If the Mailing Address is different from the Residence Address, include street address, city, state and ZIP. 
     
  5. City and County of Former Residence in Texas — Complete this section if the client was previously registered to vote in another county in Texas.
     
  6. Date of Birth — Include the date of birth in MM/DD/YYYY format.
     
  7. Gender — Completion of the section titled “Gender” is optional. Check the box for male or female. 
     
  8. Telephone Number — Completion of the section titled “Telephone Number” is optional. Enter the ten-digit phone number.
     
  9. Texas Driver’s License or Texas Personal I.D. No. — Completion of sections titled "Texas Driver's License (TDL)" or "Personal Identification Number (PID)" are required. If an applicant does not have a license or ID, check the box and enter the last four digits of the Social Security Number (SSN).

    If an applicant completes a voter registration application in a HHSC office, verification of the numbers is not required. If an applicant completes the voter registration application outside of the office and mails the form on his own, he is required to submit verification of TDL, PID or last four digits of SSN (enclosed copies in the pouch of the application).
     
  10. Perjury Statement, Signature and Date (MM/DD/YYYY) — The person applying must sign and date the form and agree to the perjury statement for it to be valid. If a mark is used in lieu of a signature, a person may witness the mark. Write the name and address of the person who witnessed the mark above the signature line. If the client cannot sign his name, the witness writes on the signature line that the client could not make a mark.

Agent — An agent may apply for voter registration for another person if that person is related to the applicant as husband, wife, father, mother, son, or daughter. The agent must also be a registered voter or have submitted an application for registration. Indicate the relationship of the agent on the application next to signature.

General Voter Registration Information

A client must be at least 17 years and 10 months old to register to vote and may register at any time. The voter registration becomes effective 30 days after it is received or on the client's 18th birthday, whichever is later. If the client moves to another county, they must re-register in the new county of residence.

Except for minimum age requirements, staff cannot make a determination about a client's eligibility to register to vote.

The voter registration application is open to the public.

Staff are prohibited from

  • influencing a client's political preference or party registration,
  • displaying any political preference or party affiliation, and
  • making any statement to an applicant where the purpose or effect of which is to discourage the client from registering to vote.

For voter registration questions or to request a Voter Registration Application in Spanish, refer the client to the

  • Texas Secretary of State website;
  • toll-free number of the Elections Division of the Secretary of State (1-800-252-8683); or
  • the number of the local county voter registrar.