Case Number: 1030689829

01/24/2023

Need Help? Call 2-1-1

or for out of the state callers,
call 1-877-541-7905
Fax: 1-877-447-2839
Chelsea Garnett
5807 Marchmont LN Mail: Texas Health and Human Services
Austin TX 78749-3556 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 02/03/2023

If you need help, call us at 2-1-1 or 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.
For help or questions about your Lone Star Card account, call 1-800-777-7328 (7EBT).
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 Page 1 of 4

12/2022 T-01020-0724914554
 Benefit programs affected and due date:

Program EDG number Due date

For Food Stamp benefits: 659165987 2/22/23

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 Page 2 of 4

12/2022 T-01020-0724914554
 LIST OF INFORMATION NEEDED AND/OR ACTION REQUIRED:
Name(s) Program(s) Information/Action Requested Acceptable Verification/Proof
Chelsea Garnett Food Stamps Provide verification of all bank account(s) Bank statement
Deposit slip
Form 1239 Verification of Bank Accounts
Statement from bank or financial institution that has
account.
Statement from the company, agency, or
organization that set up the contract or account.
Withdrawal slip
Chelsea Garnett Food Stamps Send proof this person is following parole or H1806
community supervision rules.

Form 1020-A Page 3 of 4

12/2022 T-01020-0724914554
 Texas Health and Human Services Commission
PO Box 149024
Austin Texas 78714-9024

Case Number:1030689829

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.

Form 1020B Page 4 of 4

12/2022 T-01020-0724914554
 Form H1806
December 2015
Parole / Community Supervision Report
Because you have a felony drug conviction on or after September 1, 2015, we must find out if you can get
or keep getting benefits.

Read and fill out this form.

My name -- the person on parole or under community supervision (print):

Chelsea Garnett

SNAP benefits case number: 659165987 Individual number: 702310535

Read and check an answer:

I report the following facts about me to the Texas Health and Human Services Commission
(HHSC):

I am following my parole or community supervision rules.

I am not following my parole or community supervision rules.

My answers are true: The answers I gave 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.

Sign here:

Person on parole or under community supervision Date

Return this form by:

1. Using the Your Texas Benefits app for iPhones and Androids (take photo of form, upload, and send);
2. Uploading it on YourTexasBenefits.com;
3. Faxing it to 1-877-447-2839 or
4. Mailing it to HHSC, PO Box 149027, Austin, TX 78714-9027.

T-H1806-0724914554
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 Health and Human Services Commission
PO Box 149027
Austin TX 78714-9027

Case Number: 1030689829 Date: Contact Tel #

01/24/2023 2-1-1 or 1-877-541-7905
Case Name: Chelsea Garnett

Request for Verification of Bank Accounts

This depositor is being considered for medical assistance. A signed authorization to release information is enclosed.

Name of Depositor SSN

Chelsea Garnett

Account # 1 Account # 2 Account # 3 Account # 4

Comments:

Please provide the requested information, as well as information about any additional accounts to which the individual has
access, such as IRAs, CDs and safety deposit boxes.

PLEASE PROVIDE ALL BALANCES AS OF CLOSE OF BUSINESS ON THE FOLLOWING DATES:

31st DECEMBER 2022 30th NOVEMBER 2022 31st OCTOBER 2022 30th SEPTEMBER 2022

THANK YOU for taking the time to complete all of the information on page 2. Your help is greatly
appreciated.

BANK REPRESENTATIVE - PLEASE COMPLETE AND RETURN PAGE 2

HHSC Form 1239

Page 1 / 12-2015 T-01239-0724914554
 REQUEST FOR VERIFICATION OF BANK ACCOUNTS
Complete and return this page only
TO BE COMPLETED BY BANK REPRESENTATIVE
Name of Depositor SSN
Chelsea Garnett

INTEREST PAID
ACCOUNT TYPE OF AUTHORIZED BALANCE
NUMBER ACCOUNT SIGNATURES AS OF (date) DATE HOW OFTEN
AMOUNT POSTED POSTED?

Have any accounts been closed? Yes No If yes, complete the following:

Account Number(s):

Closing Date:
$ $ $ $
Closing Balance:

Bank Name Bank Mailing Address

Telephone No. (include A/C)

Signature - Bank Representative Date

RETURN FORM TO:

Address Telephone No. Fax No.
Health and Human Services Commission PO Box 149027 2-1-1 or 1-877-447-2839
Austin TX 78714-9027 1-877-541-7905

HHSC Form 1239 T-01239-0724914554

Page 2 / 12-2015
 Form H0003
08/2015
Agreement to release your facts
To find out if you can get or keep getting benefits, we must check facts about you.
Read and fill out this form.
My name (print): Chelsea Garnett
Spouse's name (print):

I agree to allow the following organization to give facts or records about me or my spouse to the
Texas Health and Human Services Commission (HHSC):
• Employers • Government agencies
• Insurance companies • Building associations
• Real estate companies • Banks or other financial institutions

• This agreement does not include getting personal health information from doctors or other health-care
providers.

• This agreement will not end until either:

• Your application for benefits is cancelled or not approved;

• You no longer get health-care benefits through HHSC or
• You send HHSC a written statement that says you no longer want HHSC to get your facts or
records. (If you don't allow HHSC to get your facts or records, you might not be able to get
benefits.)

Sign here:

Person applying for or getting benefits Date

Spouse Date

Guardian, Power of Attorney, parent of minor child, or Date

authorized representative

Return this form by:

1. Using the Your Texas Benefits app for iPhones and Androids (take photo of form, upload, and send);
2. Uploading it on YourTexasBenefits.com;
3. Faxing it to 1-877-447-2839 or
4. Mailing it to HHSC, PO Box 149027, Austin, TX 78714-9027.

T-H0003-0724914554
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