Downloading a Form to Your Computer

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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 orReduction.
  • To notify an TANF household of ongoing TANF time limit information.


When to Prepare

Complete Form H1076-B for all TP 01 and 61 households at complete review, incomplete review, and reapplication, when providing

  • manual Form H1009 or Form H1017, and
  • information about
    • the number of months used in the client's state time limit,
    • a change in the client's state time limit at reapplication, or
    • a correction in the client's state time limit because incorrect information was previously used.

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 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, and when available, enter the number of months counted toward the time limit (See Client Screen A2 — Welfare Reform Data, "TL Months Used.")

When applicable, check the box that indicates

  • a change in the client's time limit,
  • a correction to the client's time limit, or
  • the client is penalized for non-compliance with the Choices program.