Effective Date: 
3/2001

Documents

Instructions

Updated: 7/1991

PURPOSE

To serve as a reporting document for couples who request a resource assessment.

PROCEDURE

When to Prepare

Complete Form H1272 when the couple or responsible party requests an assessment.

Number of Copies

Complete only an original.

Transmittal

Send the original to the couple or responsible party.

Form Retention

Keep in case record for three years after case is denied.

DETAILED INSTRUCTIONS

The worker completes the top portion of the form. The client completes the rest of the form.

Having trouble viewing or downloading a form?

Get Help