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Effective Date: 
10/2000

Documents

Instructions

Updated: 8/1984

Purpose

To provide the TANF worker a form for recording verification of:

  • case and relationship information from a TANF child'sbirth, hospital, or baptismal certificate; or
  • age and place of birth when a caretaker or secondparent is applying for a Social Security number.

Procedure

When to Prepare

The TANF worker completes Form H1103 when a client initially applies or adds a child to the certified group, or a caretaker or second parent applies for a Social Security number.

Instead of Form H1103, the worker may file in the case record a readable photostatic copy of the document used to verify age and relationship.

Number of Copies

The worker completes one section of one copy of Form H1103 for each certified child in the household. The worker also completes one section of the form if proof of age, relationship, and citizenship are necessary for a client to obtain a Social Security number for a caretaker or second parent (such as aunt, stepfather, and grandmother).

Transmittal

The worker files the form on the left side of the case record under "Legal."

Form Retention

Form H1103 is a permanent part of the case record and is kept until the record is destroyed.

Detailed Instructions

HHSC requires a copy of the birth certificate to verify eligibility of each child in the TANF program. Acceptable copies are those of certificates filed in the Bureau of Vital Statistics or county of birth in the United States or a copy of the birth certificate registered in a foreign country.

If a birth certificate is unavailable, the worker can use a hospital or baptismal certificate as verification. The worker must use documents only that include all the facts to fully establish the date of birth and the relationship of the child to the TANF caretaker.

If the necessary information about age and place of birth of the caretaker or second parent is not available from the child's birth record, use a section of the Form H1103 to enter the information from the caretaker's or second parent's proof of birth.

If no proof of birth is available, the worker must reach an evaluative conclusion as described in these detailed instructions.

The worker completes each item that applies for each child. The same form may be used for up to four children. If there are more than four children, the worker uses an additional Form H1103.

PAGE 1

Case Name — Enter the case name.

Address — Enter the household's address.

App. or Case No. — Enter the application or case number.

Name of Child — Enter the name of the child as shown on the birth, hospital, or baptismal certificate.

Relationship to Payee — Enter the relationship of the child to the caretaker or second parent.

Sex — Enter M or F.

Date of Birth — Enter the child's date of birth as shown on the document.

Race — Enter the child's race as shown on the document.

Name of Child on Form H1010-B — Enter the name of the child as shown on Form H1010-B.

City and State of Birth — Enter the child's place of birth as shown on the document.

Document Reviewed — Check the box to indicate the type of document viewed. If a client is unable to provide proof of birth for a child, the worker examines all available records such as school and health records, the family Bible, and insurance policies. The worker may make an evaluative conclusion concerning the child's age and relationship. If an evaluative conclusion is made, enter on the back of the form the details, charts of relationship, or any other pertinent information. The supervisor must sign the form to show concurrence with the worker's conclusion.

Does payee have document . . ? — Check the box that indicates if the caretaker or second parent has the document in his possession.

Mother's Name as Shown on Document — Enter the name of the child's mother, as shown on the document.

Age — Enter the age of the child's mother when the child was born, as shown on the document.

City and State of Birth — Enter the place where the child's mother was born, as shown on the document.

Father's Name as Shown on Document — Enter the name of the child's father, as shown on the document. If there is no father named, enter "none named."

Age — Enter the age of the child's father when the child was born, as shown on the document.

City and State of Birth — Enter the place where the child's father was born, as shown on the document.

Name of Hospital or Church — Enter the name of the hospital from a hospital certificate or the name of the church from a baptismal certificate.

File or Certificate No. — Enter the file or certificate number from the birth, hospital, or baptismal certificate.

Page — Enter the page number where the birth certificate is found at the Bureau of Vital Statistics.

Volume — Enter the volume where the birth certificate is found at the Bureau of Vital Statistics.

City, County, State — Enter the city, county, and state where the record is filed.

Signature – Worker/Date Signed — The worker signs the completed section of the Form H1103 and enters the date signed.

PAGE 2

Comments, Evaluative Conclusions, and Charts of Relationship — The worker must record complete details about an evaluative conclusion in this space.

Signature – Worker/Supervisor/Date — The worker and supervisor must sign and date the bottom of page 2 if the worker verified the child's birth by an evaluative conclusion.