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Effective Date: 



Updated: 4/2002


To provide a record of an applicant's statement of understanding of the TANF, TANF-SP, and OTTANF ineligibility period.


When to Prepare

Complete Form H1072 before authorizing OTTANF payments.

Number of Copies

Prepare three originals.


Original – Give to applicant.

Original – File in an office or unit master file.

Original – File in the case record under Form H1010-B.


See Texas Works Manager's Guide.

Detailed Instructions

Staff complete applicant identifying information and data.

Staff review each statement of Form H1072 with the applicant at each application in which the applicant opts to receive an OTTANF payment rather than TANF or TANF-SP.

The applicant or second parent must sign and date Form H1072 (in ink) in the presence of the advisor.

The certifying worker must sign and date Form H1072 (in ink) and enter his BJN and employee number.