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.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 



Updated: 4/2000


For use in determining who qualifies for the 90% earned income deduction and to track the

  • period in which it may be received;
  • maximum number of months within that period it may be received; and
  • period in which it may not be received.


When to Prepare

Complete Form H1104 whenever a TANF applicant or recipient has earnings.

Number of Copies

Complete one form for each employed member.

Case Filing

File Form H1104 on the top right side of the case record. Keep moving it up as more items are added to the folder.

Form Retention

Retain the form until there is automation in place that records and tracks the information.