Work/School

Medical Excuse
Date: ____________________

To Whom It May Concern:

Please be advised that ________________________ was seen in my office on ______⁄______⁄______.

Diagnosis:
_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________.

________________________ is able to return to work/school on: ______⁄______⁄______.

Restrictions/Limitations:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________.

If you have any questions regarding this patient please do not hesitate to contact my office.

____________________________
Doctors Signature
 DOCTOR/DENTIST EXCUSE
For
Effingham County Schools

appointment as well as information about the length of time a student should be excused
from attending school.
Date: ________________

This is to certify __________________________________________________

Appeared in my office at ____________(a.m. or p.m.) for an appointment.

The appointment was over by _________ (a.m. or p.m.).

The student should be excused for ___________________________________ (dates).

This student may return to school on _____________________________.

___________________________

DOCTOR/DENTIST EXCUSE
For
Effingham County Schools

This
appointment as well as information about the length of time a student should be excused
from attending school.
Date: ________________

This is to certify __________________________________________________

Appeared in my office at ____________(a.m. or p.m.) for an appointment.

The appointment was over by _________ (a.m. or p.m.).

The student should be excused for ___________________________________ (dates).

This student may return to school on _____________________________.

___________________________
 Doctor/Dentist/ Professional Excused Absence

(School Name)

(Provider Name)

This is to confirm that was absent from school on

(Child’s Name) (Dates)

from a.m./p.m. to a.m./p.m. for medical/dental/professional reasons.

This child appeared for an appointment in this office on

(Date)

This child is permitted to return to school on

(Date)

Limitations/Remarks:

Signature: Date:
(Medical Provider/Dentist/Professional)

Warning: Adding to, deleting from, or altering this form in any way after it is signed by the medical
provider/dentist/professional is illegal and may result in prosecution.

Original to Child Copy to School Copy to Provider

 2258 NSS: 9204-85-2436 A. MED.: 3F20060R
NOMBRE DEL PACIENTE
AURORA SANCHEZ JAIME

CURP: SAJA0606125MMCNMRA1
DELEGACIÓN: MEXICO ORIENTE - NAUCALPAN
UNIDAD: UMF NO.64 CVE PTAL. 153005252110

CONSULTORIO: 5 TURNO: VESPERTINO

15300516716812

Fecha: Jueves, 22 de septiembre del 2016

3451. ALOPURINOL TABLETA CONTIENE: ALOPURINOL 300MG ENVASE CON 20 TABLETAS.

UNA TABLETA (S) CADA 24(S) DURANTE 30 DIA(S) CANTIDAD A SURTIR 2 ENV

1956. AMIKACINA SOLUCION INYECTABLE CADA AMPOLLETA O FRASCO AMPULA CONTIENE: SULFATO DE AMIKACINA
EQUIVALENTE A 500 MG DE AMIKACINA. ENVASE CON 1 AMPOLLETA O FRASCO AMPILA CON 2 ML.

UNA AMPOLLETA (S) CADA 24(S) DURANTE 5 DIA(S) CANTIDAD A SURTIR 5 ENV

0104 PARACETAMOL TABLETA CONTIENE: PARACETAMOL 500MG ENVACE CON 10 TABLETAS.

UNA TABLETA (S) CADA 8(S) DURANTE 3 DIA(S) CANTIDAD A SURTIR ENV

GUARDAR REPOSO POR 5 DIAS, BEBER LIQUIDOS

ACUDIR AL TÉRMINO DEL TRATAMIENTO

Nombre y Zrma del médico Cédula Profesional

Matricula

FRANCISCO VARGAS HERNANDEZ 09158525

98155258

http://11.111.15.11:9080/ServiciosAuxiliares/ImpReceta.jsp
22/09/2016
 Absen ce Ex cuse Form — Request for Con sideration
(Please use one form for each missed assignment)

Last name: __________________________ First name: ____________________________

E-mail address: ______________________________________________________________
Student ID number: ______________________________ Phone: ____________________
Course number: ________ Section number: _____________ Semester/ Year: ___________
Instructor: ______________________________________

Assign m en t Missed (circle on e):

Laboratory Recitation Workshop Quiz Exam Other ___________________

Date: ________ Assignment: ___________________________________________________

Reaso n (ch eck on e) an d attach docum en tatio n :

Personal Illness/ Injury
Death of Family Member
Other _________________

Ex plan ation : _______________________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Studen t Sign ature: _______________________________________ Date: _____________

Departmental Use Only
Approved
Not Approved
Select all that apply.

NA

7 days

One commenter expressed frustration with what he believes is excessing federal government spending.
He believes LIHWAP funding is a “giveaway” and proposed other uses for LIHWAP funds (not federally
allowable under the program).

The second commenter proposed that the state use alternate methods to expedite and streamline the
application process. They propose that applicants be allowed to document their income through self-
certification, through data previously collected, or through geographic presumption. They recommend that
if evidence of COVID impact is a requirement for LIHWAP assistance, that applicants should be presumed

No changes are suggested in response to the comments. While TDHCA is using self-certification in some
pandemic-response programs in limited cases, LIHWAP is being implemented to mimic LIHEAP as much
as possible at the suggestion of HHS. Furthermore, only one of the two funding streams for LIHWAP is
described as emergency funding. As such, a self-certification – called a Declaration of Income Statement
(DIS) in LIHEAP - is only allowed when proof of income is unobtainable. See Question 1.7 for more
detailed information concerning LIHWAP income eligibility. Evidence of COVID impact is not a
requirement for LIHWAP assistance.

Texas Dept of Housing and Community Affairs

 CROSS TIMBERS COMMUNITY HEALTH CENTER

110 West Reynosa

De Leon, TX 75486

(265) 839-5687

DOCTOR EXCUSE SLIP

Date: ________________________

This is to clarify that _____________________________ (has had) an appointment at

________________________ o' clock.

___________________________________ please excuse this absent.

_____________ May return to work on _______________________.

____________ No P.E until released.

______________ May return to work without limitations.

______________________________

Physicians Signature
 2258 NSS: 9204-85-2436 A. MED.: 3F20060R
NOMBRE DEL PACIENTE
AURORA SANCHEZ JAIME

CURP: SAJA0606125MMCNMRA1
DELEGACIÓN: MEXICO ORIENTE - NAUCALPAN
UNIDAD: UMF NO.64 CVE PTAL. 153005252110

CONSULTORIO: 5 TURNO: VESPERTINO

15300516716812

Fecha: Jueves, 22 de septiembre del 2016

3451. ALOPURINOL TABLETA CONTIENE: ALOPURINOL 300MG ENVASE CON 20 TABLETAS.

UNA TABLETA (S) CADA 24(S) DURANTE 30 DIA(S) CANTIDAD A SURTIR 2 ENV

1956. AMIKACINA SOLUCION INYECTABLE CADA AMPOLLETA O FRASCO AMPULA CONTIENE: SULFATO DE AMIKACINA
EQUIVALENTE A 500 MG DE AMIKACINA. ENVASE CON 1 AMPOLLETA O FRASCO AMPILA CON 2 ML.

UNA AMPOLLETA (S) CADA 24(S) DURANTE 5 DIA(S) CANTIDAD A SURTIR 5 ENV

0104 PARACETAMOL TABLETA CONTIENE: PARACETAMOL 500MG ENVACE CON 10 TABLETAS.

UNA TABLETA (S) CADA 8(S) DURANTE 3 DIA(S) CANTIDAD A SURTIR ENV

GUARDAR REPOSO POR 5 DIAS, BEBER LIQUIDOS

ACUDIR AL TÉRMINO DEL TRATAMIENTO

Nombre y Zrma del médico Cédula Profesional

Matricula

FRANCISCO VARGAS HERNANDEZ 09158525

98155258

http://11.111.15.11:9080/ServiciosAuxiliares/ImpReceta.jsp
22/09/2016
 Doctor/Dentist/ Professional Excused Absence

(School Name)

(Provider Name)

This is to confirm that was absent from school on

(Child’s Name) (Dates)

from a.m./p.m. to a.m./p.m. for medical/dental/professional reasons.

This child appeared for an appointment in this office on

(Date)

This child is permitted to return to school on

(Date)

Limitations/Remarks:

Signature: Date:
(Medical Provider/Dentist/Professional)

Warning: Adding to, deleting from, or altering this form in any way after it is signed by the medical
provider/dentist/professional is illegal and may result in prosecution.

Original to Child Copy to School Copy to Provider

 10/28/23

Charles Washington
Wednesday, October 26, 2023

October 2?, 2023

26, 2023
 United Memorial Medical Center
510 W TIDWELL RD
Houston, TX 77091
Phone: (713) 691-8112

WASHINGTON, CHARLES B 12/20/2007 M VARON, JOSEPH MD

483432 559775 10/28/2023 10/29/2023 09:14:28 10/29/2023 12:51:42 Meadows Diagnostics COVID-19
Real Time PT-PCR
(Nasal Swab) AM PM

COVID-19 SARS-CoV-2 Positive

 United Memorial Medical Center
510 W TIDWELL RD
Houston, TX 77091
Phone: (713) 691-8112

DAVID, JORDYN C 12/20/2007 M VARON, JOSEPH MD

483432 668664 10/28/2023 10/29/2023 09:14:28 10/29/2023 12:51:42 Meadows Diagnostics COVID-19
Real Time PT-PCR
(Nasal Swab) AM PM

COVID-19 SARS-CoV-2 Positive

 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Outpatient

Pa
Paiid
d Am
A moou
unntt : $217.78

From Date:
D ate: 12/17/2021

To
To D ate
ate:: 12/17/2021

PProv
roviide
d er N ame
am e:: MEMORIAL HERMANN NORTHEAST

Provi
P roviddeer AAd
d d re ss
ss:: 18951 MEMORIAL NORTH, HUMBLE, TX 77338

Diagnoses
Diagnosis Code Description
S025XXA FRACTURE OF TOOTH (TRAUMATIC), INITIAL ENCOUNTER FOR CLOSED FRACTURE

Procedures
Procedure Description From Date To Date Provider Name
Code
99282 Emergency department visit, low to mo… 12/17/2021 12/17/2021 NEILSBERG JASON
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Outpatient

Pa
Paiid
d Am
A moou
unntt : $0.00

From Date:
D ate: 01/16/2019

To
To D ate
ate:: 01/16/2019

PProv
roviide
d er N ame
am e:: TEXAS CHILDREN'S HOSPITAL

Provi
P roviddeer AAd
d d re ss
ss:: 6621 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S069X1S UNSPECIFIED INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF 30 MINUTE…

F0781 POSTCONCUSSIONAL SYNDROME

Procedures
Procedure Description From Date To Date Provider Name
Code
99214 Established patient o!ice or other outp… 01/16/2019 01/16/2019 --
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $29.53

From Date:
D ate: 01/16/2019

To
To D ate
ate:: 01/16/2019

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S069X1D UNSPECIFIED INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF 30 MINUTE…

F0781 POSTCONCUSSIONAL SYNDROME

Procedures
Procedure Description From Date To Date Provider Name
Code
99214 Established patient o!ice or other outp… 01/16/2019 01/16/2019 HILLEBRAND MARI…
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Outpatient

Pa
Paiid
d Am
A moou
unntt : $43.34

From Date:
D ate: 12/05/2018

To
To D ate
ate:: 12/05/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDREN'S HOSPITAL

Provi
P roviddeer AAd
d d re ss
ss:: 6621 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S064X9A EPIDURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATI…

S0219XD OTHER FRACTURE OF BASE OF SKULL, SUBSEQUENT ENCOUNTER FOR FRACTURE WI…

S098XXD OTHER SPECIFIED INJURIES OF HEAD, SUBSEQUENT ENCOUNTER

Procedures
Procedure Description From Date To Date Provider Name
Code
99214 Established patient o!ice or other outp… 12/05/2018 12/05/2018 --
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $0.00

From Date:
D ate: 12/05/2018

To
To D ate
ate:: 12/05/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S064X9A EPIDURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATI…

S0219XD OTHER FRACTURE OF BASE OF SKULL, SUBSEQUENT ENCOUNTER FOR FRACTURE WI…

Procedures
Procedure Description From Date To Date Provider Name
Code
99203 New patient o!ice or other outpatient v… 12/05/2018 12/05/2018 PERRY BRENDA
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $104.25

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6621 FANNIN MC NB STE 8303, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S020XXA FRACTURE OF VAULT OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

S064X0A EPIDURAL HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS, INITIAL ENCOUNTER

V0310XA PEDESTRIAN ON FOOT INJURED IN COLLISION WITH CAR, PICK-UP TRUCK OR VAN IN …

Procedures
Procedure Description From Date To Date Provider Name
Code
99285 Emergency department visit, problem … 11/02/2018 11/02/2018 RUSSELL ERIC
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $66.66

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
P130 FRACTURE OF SKULL DUE TO BIRTH INJURY

S098XXA OTHER SPECIFIED INJURIES OF HEAD, INITIAL ENCOUNTER

S0219XA OTHER FRACTURE OF BASE OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

S064X9A EPIDURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATI…

Procedures
Procedure Description From Date To Date Provider Name
Code
70496 CT scan of blood vessel of head with co… 11/02/2018 11/02/2018 ILLNER ANNA
:
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $73.32

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
P130 FRACTURE OF SKULL DUE TO BIRTH INJURY

S098XXA OTHER SPECIFIED INJURIES OF HEAD, INITIAL ENCOUNTER

S0219XA OTHER FRACTURE OF BASE OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

S064X9A EPIDURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATI…

Procedures
Procedure Description From Date To Date Provider Name
Code
72125 CT scan of upper spine 11/02/2018 11/02/2018 ILLNER ANNA

70450 CT scan head or brain 11/02/2018 11/02/2018 ILLNER ANNA

:
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $79.53

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S098XXA OTHER SPECIFIED INJURIES OF HEAD, INITIAL ENCOUNTER

S0219XA OTHER FRACTURE OF BASE OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

S064X9A EPIDURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATI…

Procedures
Procedure Description From Date To Date Provider Name
Code
99253 Inpatient hospital consultation, typicall… 11/02/2018 11/02/2018 DAIGLE AMY
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $84.13

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TMC ORTHOPEDIC L.P.

Provi
P roviddeer AAd
d d re ss
ss:: 1614 E. LOUETTA RD, SPRING, TX 77388

Diagnoses
Diagnosis Code Description
S0219XA OTHER FRACTURE OF BASE OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

Procedures
Procedure Description From Date To Date Provider Name
Code
L0172 Cervical, collar, semi-rigid thermoplasti… 11/02/2018 11/02/2018 --
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $84.13

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TMC ORTHOPEDIC L.P.

Provi
P roviddeer AAd
d d re ss
ss:: 1614 E. LOUETTA RD, SPRING, TX 77388

Diagnoses
Diagnosis Code Description
S0219XA OTHER FRACTURE OF BASE OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

Procedures
Procedure Description From Date To Date Provider Name
Code
L0172 Cervical, collar, semi-rigid thermoplasti… 11/02/2018 11/02/2018 --
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Inpatient

Pa
Paiid
d Am
A moou
unntt : $9077.63

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/04/2018

AAd
d mi
m issi
s sion
on Ty
Typp e :: TRAUMA

AAd
dmmiis
s si
s ion
on SSource
ou rce:: PHYSICIAN REFERRAL

Ad
A dm
miisss
siion
on D ate : 11/02/2018

D
Diis
s cha
c harge
rge D ate : 11/04/2018

Di
D isc
schh arge
arge Statu
Stat us
s:: DISCHARGED TO HOME OR SELF CARE (ROUTINE DISCHARGE)

PProv
roviide
d er N ame
am e:: TEXAS CHILDREN'S HOSPITAL

Provi
P roviddeer AAd
d d re ss
ss:: 6621 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S0219XA OTHER FRACTURE OF BASE OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

S064X0A EPIDURAL HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS, INITIAL ENCOUNTER

R1110 VOMITING, UNSPECIFIED

Surgical Procedures
No surgical procedures

Procedures
Procedure Description From Date To Date Provider Name
Code
:
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $6.94

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
T1490XA INJURY, UNSPECIFIED, INITIAL ENCOUNTER

Procedures
Procedure Description From Date To Date Provider Name
Code
71045 RADIOLOGIC EXAMINATION, CHEST; SIN… 11/02/2018 11/02/2018 ORTH ROBERT
:
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $189.72

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
S064X9A EPIDURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATI…

S0219XA OTHER FRACTURE OF BASE OF SKULL, INITIAL ENCOUNTER FOR CLOSED FRACTURE

V0920XA PEDESTRIAN INJURED IN TRAFFIC ACCIDENT INVOLVING UNSPECIFIED MOTOR VEHIC…

Procedures
Procedure Description From Date To Date Provider Name
Code
99291 Critical care delivery critically ill or injur… 11/02/2018 11/02/2018 COLEMAN RYAN
:
 FAX COVER LETTER
02/14/2023
To:

THHSC

From:

SAMUEL PRYER CASE # 1041581158

Subject:

Samuel J Pryer’s SNAP Benefits Requested

Self Employment Income Form
Case Number: 1041581158
 Form H1049
December 2015-E

Facts About Self-Employment Income

Self-employment income is any money you make working for yourself or as a subcontractor.
If you have an employer who pays you and takes out taxes, you're not self-employed.

You might be self-employed if you are a: babysitter, landscaper, day laborer, house cleaner, hair stylist, auto mechanic, or
person who makes money from sales, crops, leases, commissions, fees, or anything you do or sell.

If anyone on your benefits case gets money from self-employment, you need to: (1) fill out this form and return it to us and (2)
send proof of the facts you give on this form: receipts, invoices, or other papers (all original items sent with this form will be
returned to you).

You also can send proof of the facts you give on this form by uploading your papers and forms on the
Your Texas Benefits Mobile App, or our website, YourTexasBenefits.com.

If you use this form to show your self-employment income:

• Answer all questions and sign and date at the bottom. This is your sworn statement of income.
• You can ask another person to help you fill out this form, but that person also must sign this form.
• Use more sheets of paper if you need to. You must sign and date each sheet.

1. Name (person getting money from self-employment): Samuel J Pryer

2. What type of work do you do to earn this money? Landscaping Services
3. How many hours do you work each week? 25-35 hrs / week
4. Fill out the table below to tell us how much money you get from self-employment.
• Tell us about money from self-employment from the past 2 months. If you don't get paid every month, tell us about your
most recent payments.
• List the date you were paid, who paid the money, and the amount paid.
• Add the income amounts and enter the total in the box "Total self-employment income."

How to fill out the table:

Date Who paid this money Amount paid
10/2/2022 Douglas Malone $ 30.00
10/7/2022 Steven Jones $ 35.00
10/16/2022 Sandra Malone $ 30.00
10/21/2022 Pearson Family $ 35.00
10/30/2022 Malone Residence $ 30.00
11/04/2022 Timothy Jones $ 30.00
11/10/2022 Mr Phentrous $ 40.00
11/19/2022 The Pearson’s $ 30.00
11/31/2022 Shell Gas Station $ 30.00
Total self-employment income: $ 290.00

5. Fill out the table below to tell us how much it costs for you to work (self-employment expenses).
 Form H1049
Page 2 / 12-2015-E

Expenses can include:

• Advertising (signs, flyers). • Interest paid on business loans.
• Business property. • Materials used to make a product.
• Business rent and utilities. • Operating supplies.
• Costs of labor (list each person and the amount you paid them). • Professional fees, legal fees, licenses and permits.
• Equipment. • Repairs to business equipment or vehicles.
Expenses can't include:
• Rent, taxes, utilities, or interest on mortgage for your business if it operates out of your home (unless these costs are
separate from the costs of your home).
• The cost of goods you buy for the business, but use yourself.
How to fill out the table:
• Tell us about expenses from the past 2 months.
• If you don't pay an expense every month, tell us about your most recent expenses.
• List the date of the expense, the type of expense, and the amount of the expense.
• Add the expenses and enter the total in the box "Total self-employment expenses."
Date Type of expense Amount paid
10/01/2022 Gasoline $ 10.00
10/01/2022 Electric Tree Handle Saw $ 25.00
10/16/2022 Oil/ Air Filter Replacement $ 5.00
$
11/02/2022 Trimming String Refill $ 8.00
11/02/2022 Gasoline $ 15.00
11/12/2022 Trash Bags & Supplies $ 12.00
$
$
Total self-employment expenses: $ 75.00
Reminder ► Send proof of the facts you gave on this form: receipts, invoices, or other papers.

Who must sign ► The form must be signed by the person getting self-employment income or their spouse or authorized
representative. Anyone can help you fill out the form, but that person also must sign this form.

By signing below, I agree that: The answers on this form are true and complete to the best of my knowledge.

If they aren't, I know I might: (1) be charged with a crime, and (2) have to repay benefits.

2/14/2023
Signature of person getting self-employment income Date

Signature of anyone helping you fill out this form Date

In most cases, you can see and get facts HHSC has about you. This includes facts you give HHSC and facts HHSC gets from
other sources (medical records, employment records, etc.). You might have to pay to get a copy of these facts. You can ask
HHSC to fix anything that is wrong. You do not have to pay to fix a mistake. To ask for a copy or fix a mistake, call 2-1-1 or
877-541-7905 (after you pick a language, press 2).

For Agency Use Only

Case No. Case Name
 My Health Information
This section provides you with an overview of the Health Events for the client you selected

Service Place and Dates

CCll ai
aimm Ty
Typp e :: Professional

Pa
Paiid
d Am
A moou
unntt : $86.45

From Date:
D ate: 11/02/2018

To
To D ate
ate:: 11/02/2018

PProv
roviide
d er N ame
am e:: TEXAS CHILDRENS PHYSICIAN GROUP

Provi
P roviddeer AAd
d d re ss
ss:: 6701 FANNIN ST, HOUSTON, TX 77030

Diagnoses
Diagnosis Code Description
P130 FRACTURE OF SKULL DUE TO BIRTH INJURY

Procedures
Procedure Description From Date To Date Provider Name
Code
99253 Inpatient hospital consultation, typicall… 11/02/2018 11/02/2018 MEHTA DEEPAK
:
SIMON, ALEXIS

06/24/1991

Yes

03/22/2023

0mm

Negative

LEAH KNIGHT, NP

March 24, 2023 at 5:44 PM CDT

16515 LEXINGTON BLVD, SUGAR LAND, TX 77479

Houston Police Department 0749413-21
Production

Summary

COMPLAINANT STATED HIS VEHICLE WAS STOLEN BY UNKNOWN SUSPECT

Report Officer Printed At

DARBY, S Page: 2 of 2