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 that a member
    • has received the maximum allowable months for the member's time limit,
    • is disqualified from TANF for five years,
    • is certified for transitional Medicaid, when applicable,
    • may request TANF benefits during the five year freeze out period if the member meets the criteria for a hardship exemption,
    • is certified for TANF during the five year freeze out period because the member meets the criteria for a hardshipexemption, and
    • has the right to appeal.


When to Prepare

Complete Form H1076-C when a member

  • reaches the end of a time limit,
  • is certified for TANF because the member iseligible for a hardship exemption,
  • is disqualified from TANF at the end of the timelimit or when the member does not/no longermeets hardship requirements, or
  • is certified for Medicaid on TP 29.

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 disqualification, TP 29 certification, appeal, and hardship information on Form H1009 and Form H1017.

Form Retention

File one copy in the case record under the legal section.

Detailed Instructions

Enter the name of the client who has used the maximum number of TANF months of a time limit. Check the boxes concerning TANF disqualification or hardship exemption that apply to this client. When the client is certified for TP 29, enter the months the client will receive Medicaid.

Having trouble viewing or downloading a form?

Get Help