Form H1084, Certification for Warrants Lost, Destroyed, Stolen or Not Received

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Effective Date
H1084.pdf (99.02 KB)
H1084-S.pdf (983.55 KB)


Updated: 5/2017


  • To notify Accounting Operations with a certification that a One-Time Grandparent Warrant is lost, destroyed, stolen or not received. Note: For warrants not received, wait at least 10 working days after the warrant was issued before submitting Form H1084.
  • To obtain a payee's written statement that they have not endorsed or otherwise received a One-Time Grandparent Warrant and that they understand that they are to return the warrant if they find or receive the warrant.
  • To provide a record of a payee's statement for prosecution if Texas Health and Human Services Commission (HHSC) discovers perjury or intentional program violation.


When to Prepare

Prepare Form H1084 when a client reports a One-Time Grandparent Warrant is lost, destroyed, stolen or not received.

Number of Copies

Complete an original and one copy.


Submit the original document to HHSC, Mail Code 3500, P.O. Box 13247, Austin, Texas 78711.

File a copy under "Issuance" in the case record.

Form Retention

Keep a case record copy for three years after the recipient's denial or death.

Detailed Instructions

Section A

Enter the payee name, treasury warrant number, the warrant amount, warrant date, owner's mailing address, city, state and ZIP code. Note: Obtain the treasury warrant number, warrant amount and warrant date by inquiring into the Grandparent Payment System.

Section B

Check whether the warrant was lost, destroyed, stolen or not received. After reading the last paragraph of Section B then have the client sign and date the certification. If an authorized representative is completing Form H1084, have the authorized representative sign and date the certification and then print their name on the appropriate line.