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: 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.