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Effective Date: 




Updated: 1/2020



Form 3077 is used to notify the household of:

  • Eligibility for health care assistance;
  • Date eligibility begins;
  • Responsibility to report changes; and
  • Consequences if the household does not report changes as required.


When to Prepare

Complete an original and one copy of Form 3077. Issue the original to the household and file the copy in the case record.


Form Retention

Maintain at least until the end of the third complete state fiscal year following the date on which Form 3077 is submitted.


Detailed Instructions

Client’s Name, Street Address, City, State and ZIP Code – Enter the client’s name, street address, city, state and ZIP code in the fields provided.

Date, Case Record No., Office Address and Area Code and Phone No. – Enter the date, case record number, office address and area code and phone number in the fields provided.

Eligible for health care services date – Enter the eligibility effective date.

Comments – Add any necessary comments.

Staff Signature – Staff member completing the form signs the form.