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.