TX HHS Form H1021. Payment Agreement Verbal Authorization for One-Time Debit of an Active Lone Star Food Account

The TX HHS Form H1021, Payment Agreement - Verbal Authorization for One-Time Debit of an Active Lone Star Food Account, is a crucial document that enables clients to authorize a one-time debit from their active Lone Star Food account. This form helps solve the problem of managing food assistance programs by providing a verbal authorization mechanism for clients to request a one-time payment.

The form requires essential information such as client details (name, SSN, DOB, mailing address, and telephone number), the amount of the one-time debit, and OCIS/ARTS information including claim type, begin and end dates. The Lone Star ATA Information section captures employee details, date of request, telephone number, mail code, and signature.

This form is typically used in situations where clients need to make a one-time payment from their Lone Star Food account. By completing this form, clients can authorize the requested amount to be debited from their account. Key features include the provision of client information, authorization for the one-time debit, and employee verification.

• This form is used by clients who need to make a one-time payment from their active Lone Star Food account.