Form H1017-P, Notice of Benefit Denial and Personal Responsibility Agreement (PRA) Reasons

Instructions for Opening a Form: Some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application on your desktop system. Click here for instructions on opening this form.

Effective Date

8/2023
H1017-P.pdf , H1017-PS.pdf

Instructions

Updated: 8/2023

Purpose

  • To serve as a written notice to Temporary Assistance for Needy Families (TANF) recipients or their representatives that their benefits have been forfeited and will be or have been denied as a result of failure to cooperate with the PRA.
  • To tell TANF recipients how to have their benefits reinstated.

Procedure

Attach Form H1017-P to Form H1017, Notice of Benefit Denial or Reduction, when it is determined the household is not cooperating with PRA requirements.

Number of Copies

An original and one copy.

Transmittal

Give or mail the original to the person. Scan and file a copy in the electronic case record.

Detailed Instructions

Section 1 – Noncooperation Month 

Enter the first noncompliance month in the blank provided.

Section 2 – Forfeit Month

First Month of Forfeit — Enter the first forfeit month and the second month of noncooperation.

Second Month of Forfeit — Enter the second forfeit month.

Section 3 – Noncooperation Reason 

Check the appropriate noncooperation box and enter the name of the applicable household member(s).