TX HHS Form H1134. Help Statement Verification

Form H1134, titled Help Statement Verification, is an official Texas Health and Human Services Commission (HHSC) document used to verify financial or non-financial assistance provided to a household applying for or receiving public benefits. The form is completed by a third party who gives help to the household and is used by HHSC to accurately assess eligibility and benefit amounts.

This form plays an important role in benefit determinations because outside assistance can affect household income calculations, support needs, and ongoing eligibility for certain programs.

Purpose of Form H1134

The primary purpose of Form H1134 is to document help provided by someone outside the household, such as cash contributions, payment of bills, or in-kind support like food or shelter. HHSC uses this information to understand the household’s real financial situation and ensure benefits are calculated correctly.

The form is typically requested during an application process, a renewal, or when reported information suggests that a household receives outside assistance.

Who Must Complete This Form

Form H1134 must be completed and signed by the person who provides help to the household. This may include:

• A family member who does not live in the household
• A friend or neighbor providing regular assistance
• An individual paying bills or giving cash support

The applicant or recipient of benefits should not complete this form on behalf of the helper.

Explanation of Each Section

Part I – Case Information

This section identifies the HHSC case and the people involved. It includes the case name and number, agency contact information, and details about both the household member and the person providing help. Accurate identification ensures the verification is matched to the correct case.

Part II – Help Provided

This is the core of the form. The helper must describe the type of assistance given, including:

• Whether the helper lives with the household
• Cash assistance, including amount, frequency, start date, and repayment expectations
• Non-cash help such as food, shelter, transportation, or personal items
• Household bills paid and who receives those payments
• Whether the help will continue and for how long

Clear and honest answers are essential, as this information directly affects benefit eligibility.

Part III – Signatures

The helper must sign and date the form to certify that the information provided is true and complete. Unsigned forms are considered invalid and may delay case processing.

When This Form Is Required

Form H1134 is required when HHSC needs verification of outside help, such as:

• During an initial application for benefits
• At renewal or recertification
• When reported income or expenses suggest third-party assistance
• When eligibility workers request clarification about support received

The form is not needed if the household does not receive any outside assistance.

Real-Life Examples of Use

• A parent sends monthly cash to an adult child receiving benefits and HHSC requests verification.
• A friend pays a household’s electric bill while they are unemployed.
• A relative regularly provides groceries and transportation but does not live with the household.

Common Mistakes to Avoid

• Leaving amounts or dates blank
• Understating or overstating the value of help provided
• Forgetting to sign and date the form
• Not explaining non-cash assistance clearly

Incomplete or inaccurate forms may result in delays, benefit reductions, or denial.

Documents That May Be Needed

Although Form H1134 is a standalone verification, HHSC may also request:

• Proof of bill payments
• Bank statements showing cash transfers
• Written explanations for irregular or one-time assistance

Practical Tips for Completing the Form

• Answer every question honestly and completely
• Use clear amounts and timeframes
• Explain any irregular or temporary help in the comments section
• Return the form as soon as possible using the provided envelope

Frequently Asked Questions

Does helping someone automatically reduce their benefits?

Not always. HHSC evaluates the type, amount, and consistency of help before determining any impact.

What if the help is a one-time gift?

One-time assistance should still be reported, but it may be treated differently than ongoing support.

Can I estimate amounts if they vary?

Yes, provide the best reasonable estimate and explain variations in the comments section.

What happens if I do not return the form?

The household’s benefits may be delayed, reduced, or denied due to lack of verification.

Is repayment required for cash help?

No, but HHSC needs to know whether repayment is expected to classify the assistance correctly.

Related Forms

• Application for Benefits (Texas)
• Income Verification Forms
• Expense and Shelter Cost Verification Forms

Form Details

• Form Name: Help Statement Verification
• Form Number: H1134
• Issued By: Texas Health and Human Services Commission
• Region: Texas
• Revision Date: November 2021