Form H1072, One Time Temporary Assistance for Needy Families Acknowledgement

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Effective Date

6/2025
h1072.pdf , h1072-s.pdf

Instructions

Updated: 1/2026

Purpose

Form H1072, One Time Temporary Assistance for Needy Families (OTTANF) Acknowledgement provides a record of an applicant's statement of understanding of the TANF, TANF-SP, and OTTANF ineligibility period.

Procedure

When to Prepare

Complete Form H1072 before authorizing OTTANF payments.

Number of Copies

Save a copy in the electronic case record. Upon request provide the household with a copy or a Form H1800, Receipt for Application, Medicaid Report, Verification, Report of Change (PDF).

Transmittal

Submit H1072:

Households may fax the form to 877-477-2839 or mail to:

Texas Health and Human Services Commission
P.O. Box 149025
Austin, TX 78714-9025

Detailed Instructions

Staff complete applicant identifying information and data. This includes the name of applicant, date of birth, Social Security number and application number.

Staff review each statement of Form H1072 with the applicant at each application when the applicant opts to receive an OTTANF payment rather than TANF or TANF-SP.

The applicant or second parent must sign and date Form H1072 in ink.

Note: Clients who use YourTexasBenefits.com to sign and submit their forms do not need to provide an ink signature. The online process eliminates the requirement for a traditional signature.