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- To provide a uniform method for exchanging case information between TANF, Medicaid, or TANF foster care and child support units.
- To serve as a record of information.
When to Prepare
The advisor, TANF foster care eligibility worker, or child support officer completes Form H1701 if a Form H0050 previously has been sent to the child support unit.
For generic worksheet cases, complete Form H1701 only if the client
- fails to remit child support,
- appeals a noncooperation sanction, or
- has a child who receives SSI benefits.
For Medicaid cases only: use Form H1701 to notify the Child Support Office of the action taken on a noncooperation sanction request. See Form H1708.
Number of Copies
Form H1701 is a two-part carbonless form.
If the information is furnished by a TANF, Medicaid, or TANF foster care unit, send the original to the child support unit and file the copy in the client's caserecord. If the information is furnished by a child support unit, send the original to the Texas Works or TANF foster care eligibility worker and file the copy in the absent parent's case record. Form H1701 may be sent in a standard department window envelope.
Keep all case record copies three years after the case is denied or closed.
Date — Enter the date the form is completed and signed.
From — Enter the name, complete address, unit number, region number, and mail code of the advisor, or TANF foster care worker or the child support officer initiating the form.
To — Enter the name, complete address, unit number, region number, and mail code of the advisor, or TANF foster care worker or the child support officer to whom the form is sent.
TANF/Medicaid/TANF Foster Care Case Name — Enter the TANF or Medicaid case name or the TANF foster care child's name.
TANF/Medicaid/TANF Foster Care Case No. — Enter the TANF, Medicaid, or TANF foster care case number.
Absent Parent Name — Enter the complete name of the absent parent about whom information is given.
Absent Parent Case No. (child support officer completes this item) — Enter the absent parent's case number. Include the mult number, which is the absent parent identifier.
ABSENT PARENT INFORMATION — Completed by Child Support Unit.
Absent Parent Paying Regular Support to — Check if the absent parent has been located and is now paying child support. Enter the name of the court or person who receives the child support payments.
Absent Parent Has Been Ordered To Pay Child Support — Check if the child support unit has located the absent parent and child support payments have been arranged either through a court order or by an agreement with the absent parent to pay support. Enter the amount of each payment, how often the payment is to be made (weekly, semi-monthly, or monthly), and the date the payments are to begin.
Paternity Established — Check if paternity has been established in a paternity suit.
Blood Test Results Negative — Check if the absent parent is excluded from being the father of the TANF or Medicaid children. Therefore, paternity establishment will not be pursued for this case.
Absent Parent Recipient Reconciled/Reunited — Check if the child support unit has verified that the absent parent and recipient are living together. Fill in the reconciliation date if it is known.
New Information — Check if the child support unit finds any new pertinent information about the absent parent. Enter details in the comments section.
Note: No provision is made for giving information on the absent parent's change of address to the advisor or TANF foster care eligibility worker. If the worker requires this information, enter the new address in the comments section.
TANF FOSTER CARE INFORMATION — Completed by TANF Foster Care Eligibility Worker
Parent's Address — Check only if the parent has been located or has changed address. Enter the address. Check the box that shows whether the parent has been located or has changed address.
Conference Requested — Check if the foster care child placement worker wants a conference with the child support attorney. Give reason for the request in the comments section.
Paternity Determination Requested — Check if the foster care placement worker requests that the child support unit attempt to establish the child's paternity.
Form 1744 Attached — Check if Form 1744, Identifying Data for Service of Citation, is sent to the child support unit.
Other — Check and add any additional information about the parent or child support payments that is not included in any of the previous items or the comments section.
TANF/MEDICAID RECIPIENT INFORMATION — Completed by advisor.
Recipient Reports Absent Parent Located at — Check if the recipient gives the advisor information on the location of the absent parent. Enter the complete address.
Death of Absent Parent's Child — Check to report the death of the absent parent's child. Enter the date of death, the recipient number, and the name of the child.
Absent Parent's Child Left the Recipient's Home — Check to report that the absent parent's child left the recipient's home. Enter the date the child left and the name of the child. Enter the reason. If additional space is needed, use the comments section.
Failure to Cooperate — Check if the caretaker fails to cooperate with the advisor, resulting in the removal of the caretaker's needs from the TANF grant or Medicaid case. Give the reason in the comments section.
SSI Child — Check if the caretaker has a child in the household who receives SSI benefits. Indicate the child's name, any biographical data available, and the name of the non-custodial parent.
Other — Check and add any pertinent additional information about the recipient, the absent parent, or the absent parent's children that is not included in the previous items or the comments section.
TANF/MEDICAID BIRTH INFORMATION — Completed by advisor
Birth of Absent Parent's Child — Check to report the birth of a child to the recipient. Enter the date of birth, the recipient number, the name of the child, and the place of birth including city, state, and county. If no Form H0050 has been filed for this absent parent, then complete Form H0050.
Minor Mother — If the new baby's mother is a minor mother who will continue to be included as a child on this case, check this box and give the minor mother's client number.
New Referral Form H0050 Attached — Check for a new birth referral when you have a new absent parent.
COMMENTS — Give detailed information about the previous items or any additional request for information that is not specifically mentioned in the form.