- To use as an attachment to manual
- Form H1009, TANF/Food Stamp Notice of Eligibility; or
- Form H1017, Notice of Benefit Denial or Reduction.
- To notify a TANF household of the initial TANF state time limit information that applies to the caretaker and/or second parent.
When to Prepare
Complete Form H1076-A for all TP 01 and 61 households at application, complete review, and incomplete review when providing the household
- manual Form H1009 or Form H1017, and
- initial TANF state time limit information.
Number of Copies
Complete an original and two copies.
The advisor gives an original and one copy to the client.
Note: The GWS prints the household's state time limit information on Form H1009 and Form H1017.
File one copy under Miscellaneous/Correspondence. Keep it for three years after the case is denied.
Enter the name(s) of the caretaker and/or second parent. Check the box that indicates whether the client has a time limit of 12, 24, or 36 months.
Check the "Choices Exempt" box if the client is exempt from the Choices program in order to care for a
- disabled child, or
- child under age 1.