Revision 05-4; Effective August 1, 2005

General Information

All Programs

Form H1000-A, Notice of Application, Form H1000-B, Record of Case Action, and Form H1000-C, Secondary Client Input, are manual forms used in all programs to report applications, the subsequent denial or certification of eligibility, and changes and deletions to information for certified and denied cases. Use a separate Form H1000-A, Form H1000-B or Form H1000-C to report actions taken in each individual program.

Form H1000-A is a four-part form. Each part has the same control number.

  • Part 1, Notice of Application (NOA) is a short form that
    • indicates that an application was filed and the date filed, and
    • gives information for an NOA report to field staff about individual information already in the computer file.
  • Part 2, Input Document, is a page advisors use for handwritten entries during the decision process. Use the input document to
    • report the final disposition of an application,
    • correct Items 01 through 38 already sent on the NOA,
    • authorize the issuance of benefits, or
    • establish a central file on all individual data.
  • Part 3, Case Record Copy, is a carbon copy of Part 2. It contains information on the NOA and the disposition of an application for audits.
  • Part 4, Case Index Card, is a carbon copy of the NOA used to
    • make a central file of pending applications in the local office, and
    • report changes on pending applications.

Form H1000-B is a three-part form. The assigned case number and sequence number appears on all copies of the form. To request Form H1000-B, use Form H1004, Request for Form H1000-B.

  • Part 1, Record of Case Action, is a computer-generated form that shows current case information.
  • Use the Part 2, Input Document, to
    • update information;
    • report the disposition of a redetermination; or
    • authorize, adjust, or cancel benefits.
  • Part 3, Case Record Copy, is identical to Part 2, Input Document. All items entered on the input document appear on the Case Record Copy.

Form H1000-C is a one-part form. Use this form to enter

  • start and end dates for PRA penalties and good cause,
  • finger image code and vun, and
  • disqualifications and Supplemental Nutrition Assistance Program (SNAP) work requirement countable months.

Advisors must submit Form H1000-A or Form H1000-B with Form H1000-C.


C—511 Form H1000-A

Revision 05-4; Effective August 1, 2005

All Programs

Correct any errors made on Part I, Notice of Application (NOA), before submitting the form for processing.

You must process the NOA before entering the input document information. Batch and submit the NOA before, or on the same day as, the input document.

If staff damage or lose Form H1000-A, Notice of Application, substitute the same form from another set. Block out the preprinted application number and enter the application number of the original NOA.

If the number of applicants listed on Form H1010-B, Application for Assistance - Part B: Information We Need to Know, exceeds 11 people, complete an additional set of forms. Complete Item 04, Page, on the first NOA. Block out the preprinted application number on the additional NOA forms and enter the original application number of the first NOA. Make entries in

Item 04, Page;
Item 06, Budgeted Job Number;
Item 07, Mail Code;
Item 09, Case Name; and
Items 33-38. Make sure to begin with line "b" in Items 33-38.

Staple the NOAs together and batch as one.

When an applicant moves and the move requires the transfer of a pending application to another office, forward all material, including Form H1031, Case Record Transfer. The receiving office is responsible for updating the new budgeted job number, mail code, and county number.


C—512 Form H1000-B

Revision 02-3; Effective April 1, 2002

All Programs

The Form H1000-B, Record of Case Action, input document is identical to the Form H1000-A, Notice of Application input document. The following items appear on the record of case action, input document, and case record copy:

Item 01, Case number;
Item 02, Category;
Item 03, Sequence;
Item 09, Case name; and
Item 32, Client number.

Enter changes in the case information in red ink. To report a change or correction:

  • circle the section number.
  • circle the individual line indicator in the section where the change is entered. If a change is made in Section III only, circle the individual line indicator in both Sections II and III.
  • enter the new information.
  • enter the client number in Item 50, Client Number Validation, if changing the name and date of birth of the same client.

You may not change:

Item 08, Date Filed;
Item 32, Client Number;
Item 37, Social Security Number (SSN) validated with an asterisk;
Item 38, Social Security Claim Number validated with acode 1 or 3;
Item 48, PA – Refugee; and
Item 129, Grant Effective Date(TANF only).

Additionally for TANF Medicaid Programs you may not change

Item 02, Category; and
Item 46, Medical Effective Date (over six months old).

To delete income amounts and social security account numbers without asterisks (Item 37), enter a zero in the item. Delete all other information (including the social security claim number, Item 38) by entering a pound sign (#) in the first position of the item. Do not use a pound sign as an abbreviation for number.

To delete an individual name and individual information, enter a pound sign in Item 33, Client Name. If deleting a TANF or Medical Programs individual due to death, re-enter the original status-in-group code for the deceased individual plus status-in-group code X in Item 40, Status in Group. Enter the individual's date of death in Item 47, Death/Denial Date.

If you delete a

  • TANF certified member, adjust the total needs amount in Item 66.
  • Medical Programs budget group member, adjust the total needs amount in Item 66, and the number of adults/children included in the budget group in Items 125, and 126.