Thank you for referring your neighbor to the SSA team for benefits assistance!

Need Help with Your Application?
The North Texas Food Bank can help you complete and submit your application to the Health and Human Services Commission (HHSC). While we’re happy to assist with the process, NTFB does not determine eligibility. If you’re unable to complete the form or need help, please contact our Benefits Call Center at 214-269-0906 or email snap@ntfb.org — we’re here to help!

How the process works

Step 1: Submit your information

On the next page, submit your information. The form should take about 10 minutes to complete.

Step 2: Submit proof of your living situation

This includes ID, paystubs, proof of address and expenses. You can do this during the application assistance with a navigator, using the "File Upload" section of this jotform, or within the next 30 days after submitting. You can send in via email at SNAPDocuments@ntfb.org, at your local HHSC office, by fax at 1-877-447-2839 or by mail at HHSC. P.O. Box 149027. Austin, TX 78714-0927.

Step 3. Checking the status of your case

To check the status of your case or an application, you will need to contact 211, or (877) 541 - 7905. Once you are connected, you will select your preferred language, then select option 2 for assistance with state benefits and let the virtual assistance know you want to "check the status" of your case.

Step 4: Processing and determining eligibility

Once the application is submitted Health and Human services will process and determine elegibility. You will get the response via mail at your mailing address it can take 30-45 days for HHSC to process the application. HHSC gives SNAP food benefits through the Texas Electronic Benefit Transfer (EBT) Lone Star Card. This is a plastic card that's used like a debit card. Each month, your approved monthly benefit amount is placed in the card's account

Disclosure: The North Texas Food Bank is a community partner with Health and Human Services. We will help you fill out your application and submit it to HHSC, but we do not determine eligibility. Eligibility will be determined by Health and Human Services and any correspondence will be sent to your mailing address, NTFB does not receive any information regarding your case.

Virtual Site Inquiry Submission

Important: Please do not miss our call. NTFB will call you to verify the information provided below. This submission will allow NTFB to submit your information to HHSC to determine eligibility. If you are unable to complete the following submission, please contact 214-269-0906.
Please select the agency who referred you to us here:*
Name of Referring Agency:*
Name*

First NameLast Name
Participant ID:
Date of Birth*
Date of Birth

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Email
example@example.com
What language do you prefer to speak?*
Will you need an interpreter?*

YesNo
If yes, mark the one you need:*

SpanishAmerican Sign LanguageVietnameseOther
What is your gender?*

MaleFemale
What is your race/ethnicity?

African AmericanAmerican Indian or Alaska nativeAsianHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOther/Prefer not to answer
Are you a U.S. Citizen?*

YesNo
If you are not a U.S. Citizen, are you a refugee or legally admitted immigrant?*

YesNo
Marital Status*

MarriedSingleDivorcedSeparatedWidowed
Are you going to school?*

YesNo
If yes, are you going full time?*

YesNo
Do you live in Texas and plan to live in Texas?*

YesNo
Please mark the benefits anyone on your case is interested in applying for:*

Children's MedicaidMedicaid for an Adult Caring for a ChildSNAP Food BenefitsTANF Cash Help for FamiliesMedicaid for an Adult not Caring for a ChildPregnant Women MedicaidHealthy Texas Women's Program
Please answer the following screening questions.
1. Is anyone in the home a migrant worker or seasonal farmworker?

YesNo
2. Does anyone in the home have money in the bank?

YesNo
If so, how much:*
3. Does anyone in the home expect to receive money this month? (This includes money you get from jobs, child support, social security and unemployment)

YesNo
Who is your employer?*
What is your monthly income?*
4. Does anyone in the home pay costs for housing and utilities? (This includes rent, mortgage, water, gas, electric, sewage, trash, phone and property tax)

YesNo
5. Does anyone currently receive cash help, food or health-care benefits from another state?

YesNo
6. Has anyone been convicted of a felony for conduct that: (1) took place after August 22, 1996, and (2) involved illegal drugs?

YesNo
If yes, who?
7. Is anyone living in a place of care such as homeless shelter, drug treatment center or a group home?

YesNo
If yes, who?
8. When people break program rules, they are sometimes "disqualified" from getting benefits. Is anyone living with you disqualified from getting cash help or food benefits anywhere in the United States?

YesNo
If none of the expenses below applies to you, please leave blank or enter 0 in the space provided.
How much do you pay for rent?
How much do you pay for water?
How much do you pay for electricity (light)?
How much do you pay for gas?
How much do you pay for your phone?
How much do you pay for your vehicle?
How much do you spend on food?
Total Home Costs
9. Does anyone own or is anyone paying for a car, truck, boat, motorcycle?

YesNo
If yes, please list vehicle's year, make and model:
If you have a second vehicle, please list it's year, make and model here:
People in the Home

Please list the people in your home and their relationship to you. Document first and last name. If there is not enough space, please call 214-269-0906 and complete your application with an NTFB representative.
How many people are applying for benefits in your home? If you are a single person household, please select "individual." If you are a family or group household, please select "Other" and specify in the comment box how many people are in your family household.

IndividualOther
Person 2 (you are person 1):
Person 3:
Person 4:
Person 5:
Does anyone in the home have a disability?*

YesNo
If yes, who?*
By signing below, I agree:

To let HHSC and other state, federal, and local agencies check, share, and get facts about anyone on my benefits case (the household).

To let other people, businesses, and organizations share facts they have about anyone on my benefits case (the household) with HHSC.

The facts to be checked and shared include anything that helps decide: (1) who can get benefits, and (2) the amount of benefits.

By signing, you are giving the Texas Health and Human Services Commission (HHSC) permission to release all or part of your case record, which may also include health information.

Release my information to the following person/agency:

North Texas Food Bank: 3677 Mapleshade Ln., Plano, TX 75075 and/or 4500 S. Cockrell Hill Rd., Dallas, TX 75236 | Phone: 214-269-0906

By signing below, I agree:

To let HHSC and other state, federal, and local agencies check, share, and get facts about anyone on my benefits case (the household).

To let other people, businesses, and organizations share facts they have about anyone on my benefits case (the household) with HHSC.

The facts to be checked and shared include anything that helps decide: (1) who can get benefits, and (2) the amount of benefits.

I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not, I may be subject to criminal prosecution.
Signature*

Clear
Date

MonthDayYear
Date
Medicaid Only*

Fill out this section only if the amount of money you get changes or might change from month to month. If you don’t expect changes to your monthly income, skip this question.
Your total income this year
1. Can anyone listed on this form get health insurance through a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse.

YesNo
2. Did anyone have insurance through a job and lose it within the past 3 months?

YesNo
If yes, who?
3. Is anyone who is applying for health coverage in jail(incarcerated)?

YesNo
If yes, who is in jail?
4. Is anyone an active duty member of one of these military forces? • U.S. Armed Forces • National Guard • Reserves • State Military Forces

YesNo
If yes, who?
5. Is anyone in the home pregnant?

YesNo
If yes, who is pregnant?
Number of babies expected
Is this your first pregnancy?

YesNo
What is the first and last name of the unborn child's father?
6. Renewing your health coverage in future years. To make it easier to find out if I can get help paying for health coverage in future years, I agree to allow the agency to use facts about money I get (income data), including information from tax returns. The agency will send me a notice, let me make any changes, and I can cancel (optout) at anytime. I agree: Yes, the agency can get facts listed above and renew my health coverage without asking me for the next:

5 years4 years3 years2 years1 yearDon't use information from tax returns to renew my coverage.
Signature*

Clear
Date

MonthDayYear
Date
File Upload - HHSC requires proof of income, address, expenses and IDs. If you would like to submit that information now, please click below.

Cancelof
Type a question

yes
Should be Empty:

Virtual Site Inquiry Submission

Please answer the following screening questions.

People in the Home

Medicaid Only*