Case Number: 1017321665

04/10/2021

Need Help? Call 2-1-1

or for out of the state callers,
call 1-877-541-7905
Fax: 1-877-447-2839
Ms. Gabriela Talamantes
338 Pool DR Mail: Texas Health and Human Services
San Antonio TX 78223-2452 Commission
PO Box 149024
Austin Texas 78714-9024
If you have a hearing or speech disability,
call 7-1-1 or any relay service.

To find out if you can get or keep getting benefits, we need more facts from you:
You are getting this packet because either: (1) you applied for benefits, (2) you reported a change to your case, or (3)
we must check your income to see if you can still get benefits.
Inside this packet you will find:
• A list of the items we need from you.
• A pre-paid envelope.

You also might find other forms you can fill out and send to us.
Send us the items by 04/20/2021
If you need help, call us at 2-1-1 or 1-877-541-7905. After you pick a language, press 2. We can take your call
Monday to Friday, 8 a.m. to 6 p.m. Central Time.

You still need to send us the items by this due date.

If you don't send us your items by this date,

you might not get benefits or your benefits might end.

There are 4 ways to send us the items we need:

Pick one of these ways to send the items back to us:
• YourTexasBenefits.com: You can upload your items online.

• Your Texas Benefits Mobile App: You can upload your items using the mobile app.
The app is free to download in the Google Play and Apple iTunes stores.

• Mail: Mail this letter and the items we need in the pre-paid envelope that came in this packet.

•
Fax: Fax this letter and the items we need to 1-877-447-2839.

Don't forget:
• Put your case number on everything you send us.
• If you send us a letter or statement showing proof of facts we need, make sure the person who writes it
includes: (1) their name, (2) their address, (3) their phone number, (4) the date they wrote it, and (5) their
signature.

Form 1020 /August 2016

T-01020-0625592765 Page 1 of 6
VERIFICATION OF NEW INCOME, CHANGE OF INCOME AND/OR TERMINATION OF EMPLOYMENT/INCOME
REQUIRES FORM 1028 TO BE FILLED OUT SIGNED AND DATED BY YOUR EMPLOYER, WITH THEIR CONTACT
INFORMATION (EVEN IF NO LONGER EMPLOYED). YOUR MOST RECENT PAYSTUBS ARE NOT SUFFICIENT FOR
VERIFICATION. This information may also be provided on company letterhead. Our agency does not use "The 800 Work
Number" as verification. Thank you.

Form 1020 /August 2016

T-01020-0625592765 Page 2 of 6
Benefit programs affected and due date:

Program EDG number Due date

For Food Stamp benefits: 605200846 4/20/21

If you're afraid that giving us facts about someone could cause harm (physical or emotional) to you or
your child:
If you're applying for or renewing Medicaid or CHIP benefits, you might not need to give us facts about that
person. You might be able to get the "Family Violence Exemption."
Let us know if you're afraid to give facts about someone:

• Phone: Call 2-1-1 or 1-877-541-7905 (after picking a language, press 2).

• Mail: TEXAS HEALTH AND HUMAN SERVICES COMMISSION,P O Box 149024,

Austin, Texas 78714-9024
• In person: At a benefits office. To find one near you, go to YourTexasBenefits.com or call 2-1-1 or
1-877-541-7905 (after picking a language, press 1).
• Fax: 1-877-447-2839.

Form 1020 /August 2016

T-01020-0625592765 Page 3 of 6
 LIST OF INFORMATION NEEDED AND/OR ACTION REQUIRED:
Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof
Gabriela Talamantes Food Stamps Provide verification of all money you earn from Checks, stubs, or earnings statements.
any source. Unknown Contact the employer
Data Broker
Employer.
Form 1028 Employment Verification
Form 2583 Choices Information Transmittal
TWC inquiry
Workshop or State School reimbursement officer
Gabriela Talamantes Food Stamps Provide verification of everyone who lives in Child support order
Robert Moreno your home. Child welfare records
Court record or other legal document
Form 1155 Request for Domicile Verification
Form H1857 Landlord Verification
Hospital, clinic, health dept., or doctor's records
Landlord - Non-relative
Neighbor - Non-relative
School record with address/School Official contact
Gabriela Talamantes Food Stamps Provide verification of the following missing pay Checks, stubs, or earnings statements.
period amounts from Unknown: 04/09/2021; Employer.
04/02/2021; 03/26/2021; 03/19/2021 Form 1028 Employment Verification
Gabriela Talamantes Food Stamps Provide verification of where you live. Bill/receipt/records
Child care provider
Church or baptismal record
City or crisscross directory
DPS ID
Employer
Form 1857 Landlord Verification
Home visit
Mail received with name and address
Mortgage Company Statement
Non-relative
Official records of ownership of property
Post office records
Rent/mortgage receipt
School or Day Care Record
Telephone directory
Texas Motor Vehicle Commission (DMV)
Texas driver's license (valid)

Form 1020-A / August 2016

T-01020-0625592765 Page 4 of 6
 Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof
VolAg
Voter registration card
Gabriela Talamantes Food Stamps Provide verification of your earned income for Checks, stubs, or earnings statements.
the following pay periods. Unknown: Contact the employer
03/05/2021 Employer.
Form 1028 Employment Verification
Workshop or State School reimbursement officer

Form 1020-A / August 2016

T-01020-0625592765 Page 5 of 6
 Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024

Case Number:1017321665

The enclosed Missing Information form (Form 1020) includes a list of documents you need to send to us
so we can determine your eligibility for services.

See page 1 to find out how to send us your forms.

El formulario adjunto de información faltante (Formulario 1020) incluye una lista de documentos que
usted necesita enviarnos para que podamos determiner si usted reúne los requisitos para los servicios.

Vea la página 1 para saber cómo enviarnos sus documentos.

T-01020-0625592765

Form 1020B / August 2016

Page 6 of 6
 TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

Date: 04/10/2021 Need help? Call 2-1-1 or

Case number: 1017321665 1-877-541-7905
Fax: 1-877-447-2839
Mail: TEXAS HEALTH AND HUMAN SERVICES
COMMISSION
P O BOX 149027
AUSTIN, TEXAS 78714-9027

If you are deaf, hard of hearing, or speech

impaired, call 7-1-1 or 1-800-735-2989.
All numbers are free to call.

MS. GABRIELA TALAMANTES

338 POOL DR
SAN ANTONIO TX 78223-2452

Note to Ms. Gabriela Talamantes :

This form is for your employer. They need to fill out the form and return it by 04/20/2021 . You must agree to let them give facts about you.
Fill out and sign this agreement:

I, (print your name) Ms. Gabriela Talamantes allow HHSC to give my Social Security number (SSN) to the employer listed on this form.
My SSN can be used to get facts about my employment. I also allow the employer listed on this form to give facts asked on this form to HHSC.

Sign here Date

Employer -- your help is needed:

We need proof that the following person is or was your employee.

Employee or former employee Social Security number

Ms. Gabriela Talamantes

Some employers might get tax refunds or tax credits for hiring people who get certain state benefits.
To learn more, go to TexasWorkforce.org/wotc or email the Texas Workforce Commission at [email protected].

Employer -- please follow these steps:

This person lives in a home in which someone is applying for state benefits. We need to know the amount of money this person makes or made
from this job.

1. Please fill out the “Proof of Employment” form on the next page.
2. If a question doesn't apply, mark it with "N/A."
3. Return the form by 04/20/2021
To send this back to us, you can either: (a) give it to the employee listed above,
(b) mail it in the pre-paid envelope, or (c) fax it to 1-877-447-2839.

H1028
T-01028-0625592765 03/2021
Page 1
 Texas Health and Human Services Commission
Proof of Employment
To be filled out by the employer Case number : 1017321665
1. Company or employer name: Unknown
2. Company or employer address - street, city, state, ZIP:
3. Employee name (as shown on your records):
4. Employee address (as shown on your records) - street, city, state, ZIP:
5. Is or was this person your employee? Yes No
If no: Stop here - sign and date the bottom of this form and return it.
If yes: Answer all the questions below. If a question doesn't apply, write "N/A."
6. Date hired: 7. Date of first check:
8. What type of job does or did this person have?
9. This job is or was (mark all that apply): Full Time Part time Permanent Temporary
10. Average hours per pay period:
11. Rate of pay: $ per: Hour Day Week Month Job

12. How often paid:

Daily Once a week Every 2 weeks

Twice a month Once a month Other:

13. Does or did this person get overtime pay? Yes - often Yes - rarely No - never
14. FICA or FIT withheld? Yes No
15. Is or was this person on leave without pay? Yes No

If yes: Start date of leave: End date of leave:

16. Does this person have a profit sharing or pension plan? Yes No
If yes: What is the current value? $
17. Does your company offer health insurance? Yes No

If yes: This person is: Not enrolled Enrolled with family members Enrolled for self only
If yes: Name of insurance company:
18. Do you expect any changes to the facts above within the next few months? Yes No

If yes: Explain what will change:

19. On this chart, list all money this person got from jobs or training (Need more room? Add pages with the same facts):

Date pay Date Actual Gross pay amount Other pay(include tips, EITC Advance Total Pretax
period ended received hours (before taxes taken out) commissions and bonuses) amount Contributions

20. If you entered an amount in the "Other pay" column on the chart, tell us when and how often this person gets this other pay:

21. Does this person still work for you? Yes No

If no: Date separated: Reason for separation:
Date of last check sent: Gross amount of last check sent: $

Employer - read, sign, and date:

I confirm that this information is true and correct to the best of my knowledge:

Employer -sign here Date Title Phone number H1028

03/2021
T-01028-0625592765 Page 2
Health and Human Services Commission
PO Box 149027
Austin TX 78714-9027

Form 1155/12-15
REQUEST FOR DOMICILE VERIFICATION
PETICIÓN DE DOMICILE VERIFICATION

Case Number/Núm. de Caso: 1017321665 Date: 04/10/2021 Contact Tel #

2-1-1 or 1-877-541-7905

Name of Client Case No.

Ms. Gabriela Talamantes 1017321665
Address
338 Pool DR San Antonio TX 78223-2452

The person listed above has told us that you are not related to them but are familiar with their family. To help us correctly
evaluate the household's situation, we need your assistance.

Please complete the information requested on page 2 of this letter and return it to me in the postage paid envelope
provided or fax to HHSC at 1-877-447-2839 . Please return it as soon as possible, but no later than

04/25/2021
(date)

Your help is greatly appreciated.

Nombre del Cliente Caso Núm.

Ms. Gabriela Talamantes 1017321665
Dirección
338 Pool DR San Antonio TX 78223-2452

La persona cuyo nombre aparece arriba nos dijo que no hay parentesco entre ustedes, pero que usted conoce a la
familia. Necesitamos su ayuda para poder evaluar la situación de la casa.

Por favor complete la información solicitada en la página 2 de esta carta y envíela en el sobre prepagado provisto o por
fax a HHSC al 1-877-447-2839 .Por favor, devuélvala en cuanto pueda, a más tardar para

04/25/2021
(fecha)

Agradecemos mucho su ayuda.

T-01155-0625592765
Case Number/Núm de Caso. 1017321665

DOMICILE VERIFICATION VERIFICACIÓN DE DOMICILIO

(The form must be completed by a nonrelative (Una persona que no es pariente del cliente y Form 1155
who does not live with the client.) que no vive con él debe llenar esta forma.) Page 2
Please list all of the persons living in the home, including the client named on the front of this form:
Por favor, haga una lista de todas las personas que viven en la casa. Incluya el nombre del cliente que hay al otro lado de esta
forma.

NAME RELATIONSHIP TO CLIENT NAME OF EMPLOYER

NOMBRE RELACIÓN CON EL CLIENTE NOMBRE DEL EMPLEADOR
Name of Client/Nombre del Cliente

I can verify the above information because I am:

Puedo verificar la información anterior porque yo soy:

A Neighbor An Employer A School Official A Clergy Person

Vecino Empleador Funcionario de la Escuela Clérigo

A Friend A Landlord A Child Care Provider Other (explain):

Amigo Casero Otro (explique):
Cuidador de los Niños

How long have you known the family? Years/Años Months/Meses Weeks/Semanas
¿Cuánto hace que conoce a esta familia? ...............................................

Name/Nombre
X
Signature/Firma Date/Fecha

Address/Dirección Telephone/Teléfono

T-01155-0625592765
 LANDLORD VERIFICATION /VERIFICACIÓN DEL DUEÑO
(This form must be completed by the client's landlord or a representative.)
(El dueño de la vivienda del cliente o un representante suyo debe llenar esta forma).

Client Name/Nombre del cliente Case Number/Número de caso

Ms. Gabriela Talamantes 1017321665

Please provide the tenant's complete residential address/Favor de dar la dirección completa del domicilio del rentero:
Street Address/Dirección Apt. No./Núm. de Apto. City/Ciudad ZIP
338 Pool DR San Antonio 78223

1. Date tenant moved in

Fecha en que el rentero ocupó la vivienda ....................................................................................

2. How many people live in the house or apartment?

¿Cuántas personas viven en la casa o en el apartamento? ................................................................

3. List the names of all people who live in the house or apartment. List their employer, if known:
Dé el nombre de las personas que viven en la casa o en el apartamento. Si sabe el nombre del empleador de cada
persona, escribalo:
Name of Person Working?/¿Trabaja? Employer
Nombre de la Persona Yes /Sí No Empleador

4. Questions about the rent payment: /Preguntas sobre el pago de la renta:

Amount of Rent/Cantidad del pago Tenant's Portion of Rent/Porción Person making payment/¿Quién paga?
que paga el rentero
$ $
How often paid? /¿Con qué frecuencia se paga la renta?
Weekly Cada Every Two Weeks Twice a Month Monthly
Semana Cada Quincena Dos Veces al Mes Cada Mes

Method of payment? /¿Cómo se paga?

Cash En Check Money Order Other (explain):
efectivo Cheque Giro Postal Otro (explique):

Is the tenant current in paying the rent? Yes What is the total amount of past due rent?
No ¿Cuánto se debe de renta?
Si
¿Está al día en el pago de la renta? ...........
If "No," when was the last month rent was paid?
Si marca "No", ¿cuál fue el último mes que pagó? $

Form H1857 T-01857-0625592765

Page 1 / 08-2012
 5. Questions about the utilities/Preguntas sobre los servicios públicos:

Are all utilities included in rent? Yes

No
¿Están incluidos los servicios públicos en la renta? ....................................... Si

Utilities the Tenant is responsible for paying (check all that apply): Gas Electric Telephone
Servicios públicos que el rentero tiene que pagar (marque los que apliquen): Electricidad Teléfono
Utility Company
Utility bills are paid directly to: Landlord
Compañía de servicios
Las cuentas de los servicios se pagan directamente a: .................................. Dueño
públicos

Landlord or Representative Name (printed)/

Nombre del Dueño de la vivienda o de su
Representante (en letra de molde)

Signature - Landlord or Representative Date/Fecha

Firma - Dueño o su Representante
Business Address or Residential Address/Dirección del Negocio o Dirección del Domicilio Telephone/Teléfono

Form H1857
Page 2 / 08-2012 T-01857-0625592765
 LANDLORD VERIFICATION /VERIFICACIÓN DEL DUEÑO
(This form must be completed by the client's landlord or a representative.)
(El dueño de la vivienda del cliente o un representante suyo debe llenar esta forma).

Client Name/Nombre del cliente Case Number/Número de caso

Ms. Gabriela Talamantes 1017321665

Please provide the tenant's complete residential address/Favor de dar la dirección completa del domicilio del rentero:
Street Address/Dirección Apt. No./Núm. de Apto. City/Ciudad ZIP
338 Pool DR San Antonio 78223

1. Date tenant moved in

Fecha en que el rentero ocupó la vivienda ....................................................................................

2. How many people live in the house or apartment?

¿Cuántas personas viven en la casa o en el apartamento? ................................................................

3. List the names of all people who live in the house or apartment. List their employer, if known:
Dé el nombre de las personas que viven en la casa o en el apartamento. Si sabe el nombre del empleador de cada
persona, escribalo:
Name of Person Working?/¿Trabaja? Employer
Nombre de la Persona Yes /Sí No Empleador

4. Questions about the rent payment: /Preguntas sobre el pago de la renta:

Amount of Rent/Cantidad del pago Tenant's Portion of Rent/Porción Person making payment/¿Quién paga?
que paga el rentero
$ $
How often paid? /¿Con qué frecuencia se paga la renta?
Weekly Cada Every Two Weeks Twice a Month Monthly
Semana Cada Quincena Dos Veces al Mes Cada Mes

Method of payment? /¿Cómo se paga?

Cash En Check Money Order Other (explain):
efectivo Cheque Giro Postal Otro (explique):

Is the tenant current in paying the rent? Yes What is the total amount of past due rent?
No ¿Cuánto se debe de renta?
Si
¿Está al día en el pago de la renta? ...........
If "No," when was the last month rent was paid?
Si marca "No", ¿cuál fue el último mes que pagó? $

Form H1857 T-01857-0625592765

Page 1 / 08-2012
 5. Questions about the utilities/Preguntas sobre los servicios públicos:

Are all utilities included in rent? Yes

No
¿Están incluidos los servicios públicos en la renta? ....................................... Si

Utilities the Tenant is responsible for paying (check all that apply): Gas Electric Telephone
Servicios públicos que el rentero tiene que pagar (marque los que apliquen): Electricidad Teléfono
Utility Company
Utility bills are paid directly to: Landlord
Compañía de servicios
Las cuentas de los servicios se pagan directamente a: .................................. Dueño
públicos

Landlord or Representative Name (printed)/

Nombre del Dueño de la vivienda o de su
Representante (en letra de molde)

Signature - Landlord or Representative Date/Fecha

Firma - Dueño o su Representante
Business Address or Residential Address/Dirección del Negocio o Dirección del Domicilio Telephone/Teléfono

Form H1857
Page 2 / 08-2012 T-01857-0625592765