Form H1073 - Personal Responsibility Agreement

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Form H1073
Personal Responsibility Agreement
April 2014-E
Individual Name
Case Name
Case Number
What Is TANF?
Temporary Assistance for Needy Families (TANF) is temporary cash and medical assistance for families with children who are deprived of
parental support. Eligible families receive a monthly cash grant and Medicaid benefits until they become self-sufficient. In some situations the
assistance may be limited to a specific time period.
What Are Your Responsibilities?
You are responsible for the physical, emotional and financial well-being of your child. You are therefore responsible for meeting personal
responsibility requirements.
A TANF payee or disqualified adult must meet the following requirements:
1. You must cooperate with child support requirements to establish paternity and help obtain child support for children on your case.
2. You must ensure that your child gets a medical checkup as scheduled through the Texas Health Steps program.
3. Your child must be current with the required immunizations.
4. You must ensure that each child receiving TANF who is younger than 18 or a teen parent younger than 19 attends school regularly, unless
the child has a high school diploma or a general equivalency diploma (GED).
5. You must ensure that each parent or relative of a child receiving assistance not use, sell or possess controlled substances or abuse
alcohol after signing this agreement.
A TANF caretaker or second parent must meet the following requirements:
1. Each adult member of your household who gets cash assistance must participate in the Choices program as required.
2. You must cooperate with child support requirements to establish paternity and help obtain child support for children on your case.
3. You must ensure that each adult or teen parent not voluntarily quit a job without good cause.
4. You must ensure that your child gets a medical checkup as scheduled through the Texas Health Steps program.
5. Your child must be current with the required immunizations.
6. You must ensure that each child receiving TANF who is younger than 18 or a teen parent younger than 19 attends school regularly, unless
the child has a high school diploma or a GED.
7. You must ensure that each TANF recipient attends parenting skills classes if requested to do so.
8. You must ensure that each parent or relative of a child receiving assistance not use, sell or possess controlled substances or abuse
alcohol after signing this agreement.
You must truthfully represent your situation in completing your application, your interview; providing proof of your situation; reporting changes in
address, income, assets and family size; and by keeping or rescheduling all appointments.
What Are the State's Responsibilities?
The state will assist you in becoming self-sufficient by:
Providing help in finding employment and necessary support services within available resources.
Providing support services to strengthen the family, such as life skills and parenting skills training.
Providing timely, accurate and easily accessible benefits.
Promoting the development of community resources.
Penalty for Failure to Cooperate with the Personal Responsibility Agreement
If you fail to cooperate with any of the Personal Responsibility Agreement (PRA) requirements, you and your entire family will not receive TANF cash
assistance for one month or until you cooperate, whichever is longer.
If you fail to cooperate with the PRA for two months in a row, your TANF case will be denied. When you re-apply for TANF cash assistance, you must
cooperate with all requirements of the PRA for one month before your family can again receive TANF cash assistance.
Also, if you fail to cooperate with the Choices work or child support requirements, you will not receive Medicaid for one month or until you cooperate,
unless you are pregnant or under age 19. Your other family members who are receiving Medicaid will remain eligible for Medicaid.
If you don't follow the Choices work rules, the people on your benefits case might not get SNAP food benefits.
When you are informed that you didn’t cooperate with one of your responsibilities, it is very important that you start cooperating with the requirements
immediately. If you receive a notice that you or a family member has failed to cooperate with the Choices work requirement, without good cause, you
must report to your local workforce center and begin participating as soon as possible to prevent denial of your case.
By signing this form I certify that I am aware of my responsibilities and have been given a copy of them. I will explain these responsibilities to
other members of my household. I understand that a penalty may be applied to my case if I or other members of my household do not meet
their responsibilities. I have also received additional information regarding the Choices program and child support requirements.
Signature – Applicant/Recipient
Date
Signature – Advisor
Date

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