To obtain a written statement from an applicant or recipient that the household:
- has not previously received benefits in that month; or
- had food destroyed that was purchased with SNAP benefits.
To provide a record of a person's statement for use if HHSC discovers perjury or an intentional program violation.
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.
Save a copy in the electronic case record.
Staff complete Form H1855 per information supplied by the household.
The head of the household, spouse, responsible household member or authorized representative (AR) must sign Form H1855. Ensure that the person reads the form and understands what they are signing.
If the person cannot to come to the HHSC office to complete Form H1855, staff must:
- allow the AR to take the form to the person and return it to HHSC;
- mail the form to the person with a postage paid return envelope; or
- schedule a home visit.
The local HHSC 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 office; and
- cannot appoint an AR.
Allow the AR to sign Form H1855 only if the:
- applicant is interviewed by phone; or
- AR completes the interview for the applicant.
Case Name — Enter the name of the head of the household as listed in the case record.
Case No. — Enter the household’s SNAP case number.
Current Address — Enter the household's current mailing address.
Complete the following when replacing benefits:
Date Reported — Enter the date the client requested the replacement.
Date Received — Enter the date HHSC received the signed form.
Old Address — Enter the client's old address, if different from the current address.
Benefit Month and Year and Allotment Amount — The month and year for which the benefit was issued and the amount of the allotment.
Original Issue Date — If applicable, the issue date of the issuance used to purchase food reported as destroyed.
Ensure that the month shown in the identifying information at the top of the form and the month shown in the lower section are the same when providing replacement benefits.