Effective Date
Instructions
Updated: 4/2026
Purpose
This form is an optional form for clerks to use as a desk aid or to screen every Supplemental Nutrition Assistance Program (SNAP) application to determine eligibility for expedited services.
Note: This form must be considered part of the case record if it is used.
Procedure
When to Prepare
Not applicable if used as a desk aid.
The clerk completes Form H1105 when screening a SNAP application or redetermination for expedited benefits.
Number of Copies
Not applicable if used as a desk aid.
If Form H1105 is used to screen a SNAP application or redetermination, image the form to the case record.
Transmittal
Not applicable if used as a desk aid or imaged to the case record.
Detailed Instructions
Case Name – Enter the Case Name.
Case No. – Enter the Case Number.
Complete lines 1 through 14 with the household’s case specific information.
Application Screened by – Print the name of the HHSC staff completing the Form H1105.
Date Screened – Enter the date the HHSC staff completed the Form H1105.