Form H1855 "Affidavit for Nonreceipt or Destroyed Supplement Nutrition Assistance Program (Snap) Benefits" - Texas

What Is Form H1855?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form H1855 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form H1855 "Affidavit for Nonreceipt or Destroyed Supplement Nutrition Assistance Program (Snap) Benefits" - Texas

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Form H1855
July 2021-E
Affidavit for Nonreceipt or Destroyed
Supplement Nutrition Assistance Program (SNAP) Benefits
Case No.
Certifying Office
Case Name
Date Reported
Date Received
Current Address
City
State
ZIP Code
Priority benefits issued while TIERS was down
My household has not been issued and has not received SNAP benefits for the month of
.
MM/YYYY
Replacement Benefits
Old Address (if applicable)
Benefit Date
Allotment Amount
Original Issuance No.
Original Issue Date
(MM/YYYY)
Some of my household's food bought with SNAP benefits was destroyed in a household disaster on
.
MM/DD/YYYY
The amount destroyed was
.
If this affidavit is not signed and received by the local office within 10 days of the date of the report, no replacement will be made.
I certify that the statement checked above is true and correct. I understand that any person who obtains or uses SNAP
benefits for which they are not eligible can be charged with a criminal offense. If convicted, the person may be fined,
imprisoned, or both.
Signature — Head of Household or Responsible Family Member
Date
Form H1855
July 2021-E
Affidavit for Nonreceipt or Destroyed
Supplement Nutrition Assistance Program (SNAP) Benefits
Case No.
Certifying Office
Case Name
Date Reported
Date Received
Current Address
City
State
ZIP Code
Priority benefits issued while TIERS was down
My household has not been issued and has not received SNAP benefits for the month of
.
MM/YYYY
Replacement Benefits
Old Address (if applicable)
Benefit Date
Allotment Amount
Original Issuance No.
Original Issue Date
(MM/YYYY)
Some of my household's food bought with SNAP benefits was destroyed in a household disaster on
.
MM/DD/YYYY
The amount destroyed was
.
If this affidavit is not signed and received by the local office within 10 days of the date of the report, no replacement will be made.
I certify that the statement checked above is true and correct. I understand that any person who obtains or uses SNAP
benefits for which they are not eligible can be charged with a criminal offense. If convicted, the person may be fined,
imprisoned, or both.
Signature — Head of Household or Responsible Family Member
Date