Effective Date: 



Updated: 4/2002


  • 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.

Form Retention

File one copy under Miscellaneous/Correspondence. Keep it for three years after the case is denied.

Detailed Instructions

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.

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