Form H1073, Personal Responsibility Agreement

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Effective Date

1/2026

Instructions

Updated: 1/2026

Purpose of the Personal Responsibility Agreement (PRA)

  • Provides staff with a standardized summary to inform applicants and recipients of their responsibilities as participants in the TANF (TP 01, 61) program.
  • Emphasizes the message of personal responsibility and self-sufficiency with recipients.

Procedure

When to Prepare

Form H1073 must be signed by:

  • caretakers and second parents who receive TANF including teen parents that are caretakers, at first or subsequent interviews if a signed form is not already on file or there has been a break in certification; and
  • payees and disqualified parents if a signed form is not already on file or there was a break in certification.

Notes:

  • If the second parent is in the home, they must sign a separate form.
  • If the caretaker, second parent, payee or disqualified adult refuses to sign Form H1073, deny the case.

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.

Transmittal

Submit Form H1073:

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

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

Detailed Instructions

Staff complete applicant identifying information and data such as person’s name, and case name and number.

What are Your Responsibilities?

Staff should refer to the Texas Works Handbook A-2100, Personal Responsibility Agreement. This explains each responsibility and the related penalties for each client and HHSC's tasks to provide support service.

Information on Additional Penalties

Continue to provide clients with Form H1712, Explanation of Child or Medical Support, Family Violence and Good Cause, and Form H2580, TANF Employment Services Notice.

The caretakers, second parent, payee, or disqualified adult must sign and date Form H1073 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.