Form H1852, List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP)

Instructions for Opening a Form

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Effective Date
01/2022
H1852.pdf (113.32 KB)

Instructions

Updated: 1/2022

Purpose

To provide a reporting form for SNAP participating drug and alcohol treatment or group living arrangement facilities. It is to report the monthly status of residents to the local Texas Health and Human Services Commission (HHSC) benefits office. 

Procedure

When to Prepare

Provide Form H1852 to the facility authorized representative (AR) when the facility is certified and when the facility AR requests the form.

The facility AR completes the form by the fifth day of every month, or the following business day if the fifth is not a business day.

Create a special file for each center served. Information contained in these reports may be used during required on-site investigations.

Number of Copies

The facility prepares an original and one copy.

Transmittal

The facility returns the original to the appropriate HHSC benefits office. The facility maintains the copy in the facility’s records.

Detailed Instructions

Month and Year — Enter the month and year being reported.

Name of Facility — Enter the name of the drug and alcohol treatment center or group living arrangement facility. 

Name of Resident — Enter the names of the residents certified to participate for the month being reported, as the names appear on Texas Health and Human Services Commission (HHSC) SNAP notices and records for the individuals.

Date of Birth — Enter the resident’s date of birth.

EDG No. — Enter the SNAP Eligibility Determination Group (EDG) number. This number can be found on the person’s certification notice. The last number of a case’s SNAP EDG number determines when benefits are issued to the associated SNAP food account. See Form H1184, Benefit Issuance Schedule, for exact dates.

Date Entered Facility — Enter the date the resident entered the facility.

Date Departed Facility — Enter the date the resident left the facility.

Departure Announced — Complete the appropriate following entries if the resident’s departure from the facility was announced.

Card Ret’d? — Did the facility return the Lone Star Card to the local HHSC benefits office? Enter Y or N.

Returned Benefits — Enter the dollar amount of SNAP food benefits returned to the resident (that is, amount of food account balance).

Report Form? — Did the facility give Form H1019, Report of Change, or Form H1019-S, Report of Change (Spanish), to the resident? Enter Y or N.

Date Action Taken — Enter the date the facility took the preceding action.

Departure Unannounced — Complete the appropriate following entries if the resident’s departure from the center was unannounced. 

Card Ret’d? — Did the facility return the Lone Star Card to the local HHSC benefits office? Enter Y or N.

Returned Benefits — Enter the dollar amount of SNAP food benefits returned to the resident (that is, amount of food account balance).

Report Form? — Did the facility give Form H1019 or Form H1019-S to the resident? Enter Y or N.

Date Action Taken — Enter the date the facility took the preceding action.

Signature — Signature of facility employee authorized to make this report.

Date — Date signed.

Title — Title of employee making this report.