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Effective Date: 
4/2019

Documents

Instructions

Updated: 4/2019

Purpose

  • To provide a form for employment contractor staff to use to notify HHSC when a client voluntarily withdraws from TANF instead of participating with Choices.
  • To provide a form for Texas Works advisors to use when a client reports that he wants to withdraw from TANF instead of participating with Choices.

Procedure

When to Prepare

Employment contractor staff and Texas Works staff use this form to document a TANF client's decision to withdraw from the TANF program.

Number of Copies

  • Employment contractor staff complete an original and two copies.
  • Texas Works staff complete an original and one copy.

Transmittal

  • Employment contractor staff send the original to local staff, give one copy to the client, and retains copy two.
  • Texas Works staff give one copy to the client and retains the original.

Form Retention

  • Employment contractor staff retains the form in the case record three years from the date of case closure.
  • Texas Works staff file Form H1802 under Legal and retain it according to the instructions in the Texas Works Manager's Guide.

Detailed Instructions

Client's Name — Enter the name of the client required to participate in Choices.

Client's SSN — Enter the social security number of the client required to participate in Choices.

Case Name — Enter the name of the TANF case in which the client is included. If the client name is the same as the case name, enter same.

Address — Self-explanatory.

Phone No. — Self-explanatory.

Family Member's Name — Enter the name of all clients who are pregnant or have given birth in the past two months who will be denied TANF.

SSN — Enter the social security number of the family members who are pregnant or have given birth in the past two months who will be denied TANF.

Signature — Signature of client required to participate in Choices.

Date — Self-explanatory.