Snap: Social Security Number and Human Services Commission
Your Texas Benefits: Form
Please use dark ink. Please print. If you need more room, add pages. ) like this Fill in the circles (
Section A
Mark the benefits anyone on your case is applying for:
●
Your Facts
If you’re applying to get SNAP food benefits, the first month’s amount will be based on the date we get pages 1 and 2. Other benefits also are based on when we get pages 1 and 2.
Food Benefits (SNAP)
Cash Help for Families (TANF)
Health Care (Medicaid or CHIP): Children Adult Caring for a Child Pregnant Woman
Person 1: contact person or head of household
Melissa
First name
A
Middle name
Maldonado
Last name
6
2
9
-
0
7
-
9
6
0
2
0
5
Social Security number
Birth date (month/day/year)
/ 1 6 / 1 9 8 9
419 Endicott, unit 2
If you send only pages 1 and 2 now, you will still need to fill out the rest of the application to get benefits.
You have the right to file this form immediately if it has your name, address, and signature.
Mailing address
San Antonio
City
Texas
State
78214
ZIP
(210) 834-9843
Home phone 419 Endicott, unit 2 Home address
(210) 834-9843
Cell or daytime phone
Bexar
County
San Antonio
City
Texas
State
78214
ZIP
Section B
You might be able to get SNAP food benefits the next work day based on your answers to these questions. Answer them for everyone living in your home.
1. Is anyone a migrant worker or seasonal farm worker? ......................................... 2. Is the total amount of money that everyone has today $100 or less? (include cash and money in the bank) ............................................................... 3. Do you expect the total amount of money everyone will have this month to be less than $150? ................................................................ 4. Is the amount of your housing bills more than the amount of money (cash and money in the bank) everyone expects to have this month?
Please use dark ink. Please print. If you need more room, add pages. ) like this Fill in the circles (
Section A
Mark the benefits anyone on your case is applying for:
●
Your Facts
If you’re applying to get SNAP food benefits, the first month’s amount will be based on the date we get pages 1 and 2. Other benefits also are based on when we get pages 1 and 2.
Food Benefits (SNAP)
Cash Help for Families (TANF)
Health Care (Medicaid or CHIP): Children Adult Caring for a Child Pregnant Woman
Person 1: contact person or head of household
Melissa
First name
A
Middle name
Maldonado
Last name
6
2
9
-
0
7
-
9
6
0
2
0
5
Social Security number
Birth date (month/day/year)
/ 1 6 / 1 9 8 9
419 Endicott, unit 2
If you send only pages 1 and 2 now, you will still need to fill out the rest of the application to get benefits.
You have the right to file this form immediately if it has your name, address, and signature.
Mailing address
San Antonio
City
Texas
State
78214
ZIP
(210) 834-9843
Home phone 419 Endicott, unit 2 Home address
(210) 834-9843
Cell or daytime phone
Bexar
County
San Antonio
City
Texas
State
78214
ZIP
Section B
You might be able to get SNAP food benefits the next work day based on your answers to these questions. Answer them for everyone living in your home.
1. Is anyone a migrant worker or seasonal farm worker? ......................................... 2. Is the total amount of money that everyone has today $100 or less? (include cash and money in the bank) ............................................................... 3. Do you expect the total amount of money everyone will have this month to be less than $150? ................................................................ 4. Is the amount of your housing bills more than the amount of money (cash and money in the bank) everyone expects to have this month?