Form H1855, Affidavit for Nonreceipt or Destroyed Supplemental Nutrition Assistance Program (SNAP) Benefits

Instructions for Opening a Form

Some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 10/2024

Instructions

Updated: 8/2023

Purpose

To obtain a written statement from an applicant or recipient that the household:

  • has not previously received benefits in that month; or
  • had destroyed food purchased with SNAP benefits.

To provide a record of a person's statement for use if HHSC discovers perjury or an intentional program violation (IPV).

Procedure

When to Prepare

Complete Form H1855 before:

  • replacing food purchased with SNAP benefits that were reported destroyed; or
  • issuing priority benefits when TIERS is unavailable.

Number of Copies

Prepare an original.

Transmittal

Save a copy in the electronic case record. 

Detailed Instructions

HHSC local office staff complete Form H1855 using information supplied in-person by the household.

The head of the household (HOH), responsible household member, or authorized representative (AR) must sign Form H1855. Confirm that the person reads the form and understands the information before they sign.

If the person cannot come to the HHSC local office to complete Form H1855, staff must:

  • mail the form to the person with a postage paid return envelope; or
  • schedule a home visit.

The HHSC local office mails Form H1855 only for a person who:

  • is 60 or older;
  • has a disability; or
  • has difficultly with the distance to the HHSC local office; and
  • cannot appoint an AR. 

Allow the AR to sign Form H1855 only if the:

  • HOH or a responsible household member is interviewed by phone; or
  • AR completes the interview for the household.

Part I

SNAP Household Information — HHSC local office staff complete Part I with the head of household’s (HOH’s) information. The HOH should also be the primary cardholder on the EBT account.

Case No. — Enter the household’s SNAP case number.

HHSC Office — Enter the HHSC local office accepting the signed Form H1855.

Case Name — Enter the name of the HOH as listed in the case record.

Current Mailing Address — Enter the street address where the household receives mail.

City — Enter the city where the household receives mail. 

State — Enter the state where the household receives mail. 

Zip Code — Enter the zip code where the household receives mail. 

Date of Discovery — Enter the date the household initially discovered the destroyed food.

Date Reported — Enter the date the household initially reported the destroyed food to HHSC.

Date HHSC Received Form H1855 — Enter the date HHSC received the signed form.

Part II 

Priority Benefits Issued While TIERS was Down — HHSC staff complete Part II to request benefit issuance for a SNAP household who has not received their monthly benefit allotment.

My household has not been issued and has not received SNAP benefits for the month of — Enter the month and year the household did not receive their monthly benefit allotment.

Part III 

Destroyed Food Replacement Request — HHSC staff complete Part III to request benefit issuance for a SNAP household discovered food purchased with their SNAP benefits was destroyed.

Old Address — Enter the client's old address, if different from the current address.

Original Issuance Month (MM/YYYY) — Enter the month and year the benefit was originally issued.

Monthly Benefit Amount — Enter the household’s monthly allotment amount for the month the benefit was initially issued. 

Original Issuance Date — If applicable, enter the date of issuance used to purchase food reported as destroyed.

Part IV

Affidavit Signature — The HOH, responsible household member or AR must provide identity verification before writing their name in the signature line and signing the form in front of staff.

Signature — Head of Household or Responsible Household Member — The HOH, responsible household member or AR signs the form. HHSC local office staff must witness the person signing the form unless the form was mailed. By signing Part IV, the HOH, responsible household member or AR swears under penalty of perjury that the value of the food purchased with SNAP benefits destroyed in the household disaster is correct.

Date — The person signing the form enters the date that HHSC local office staff witnessed them signing the form or the date that they signed the form if mailed.