Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

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Effective Date: 



Updated: 7/1985


  • To provide the income assistance office with a record of case actions.
  • To provide the income assistance supervisor with a source for selecting cases to read.
  • To monitor caseloads.


When to Prepare

Clerical staff make individual entries for each case when it is processed.

Number of Copies

The clerical staff complete an original and one copy for each worker.


The clerical staff keep the original and give the copy to the worker.

Form Retention

Staff keep Form H1041 for as long as it is useful.

Detailed Instructions

Enter at the top of the form the worker's name, unit number, and the period of time covered by the report.

Date, Case Name, Category, Case No. — Self-explanatory.

Type of Action — Enter the three-digit code given on Form H1000-A/B which describes the type of action.

Decision — Check the column describing the decision. The columns are coded:

R — Raised grant
L — Lowered grant
S — Sustained
G — Granted or Certified
D — Denied

The columns without headings are reserved for local use.