Form H1021, Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account

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Effective Date
H1021.pdf (31.45 KB)
H1021.doc (110 KB)


Updated: 1/2002


To allow a household to verbally agree to pay a food stamp claim by a one-time debit of an active Lone Star food account.


When to Prepare

OIG or ARTS staff completes Form H1021 when a household requests to have a one-time debit of an active Lone Star food account to pay a food stamp claim.

Number of Copies

Complete an original and one copy.


Original — Lone Star Technology
Copy — OIG/ARTS office file

Form Retention

The case folder file is retained for three years or until the claim is repaid, whichever is greater.

Detailed Instructions

  1. Obtain and enter information from the client to verify identity. Verify the client information on SAVERR.
  2. Enter OCIS information when the request is made prior to claim establishment. Enter ARTS information when the request is made after claim establishment.
  3. Enter Lone Star Technology ATA information.
  4. Enter the name, telephone number, and mail code of the OIG or ARTS employee who received the request, the date of the request, and the OIG or ARTS employee's signature.