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Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
- To serve as a written notice to clients or their representatives that their benefits have been reduced or denied, a protective payee is required, the reason for the action and the effective date of the action.
- To tell clients how to have their cases reopened.
- To inform clients or their representatives of their rights to a fair hearing, an informal meeting and continued benefits.
- To inform clients or their representatives of the fair hearing procedures and free legal services.
- To inform clients about Certificates of Coverage.
When to Prepare
The worker completes Form H1017 if reducing benefits or if denying the client's application or active case or if a protective payee is assigned (or continued in mismanagement situations).
Number of Copies
An original and two copies. Note: Generic Worksheet is programmed to print two copies of Form 1017.
Give or mail the original and one copy to the client on the same day it is printed. File one copy in the case record under the legal section.
If the client signs and returns Form H1017 showing they want to appeal, send the returned form with Form H4800, Fair Hearing Request
Summary, and attachments to the hearing officer. The client may also request a hearing in person or by phone.
Note: For SAVERR cases, certification office staff give or mail the client both copies of the computer-printed Form H1017 with Form H1017-A, Notice of Benefit Denial or Reduction - Client Rights/Responsibilities, attached. If the client returns a copy of the computer-printed Form H1017 showing they want to appeal, staff send this copy with Form H4800 to the hearing officer.
Page 1 of Form H1017
At the top, enter:
- the client's name and address;
- the case or application number (SNAP for Supplemental Nutrition Assistance Program food benefits, TANF for Temporary Assistance for Needy Families, Medicaid numbers);
- the date the form is given to the client;
- the name of the certifying staff person completing the form;
- the office address and phone number and the regional hotline number; and
- information about free legal services. If none, enter "none available."
Enter in the first line the specific policy section that is the basis for the action. If there is more than one handbook section, enter the section that most closely corresponds to the Form H1000-A, Notice of Application, or Form H1000-B, Record of Case Action, code.
Note: When denying an application because of excess income or resources, use the charts found in Texas Works Handbook C-241, TANF and Medical Programs Chart, and C-242, SNAP Chart, for the appropriate handbook reference.
Mark the appropriate box for the action taken.
TANF — Enter X in the first box and X in the box indicating the TANF check will be lowered. Enter the old and new amounts of the check. Enter the first day of the month, the month and year the decrease will start.
SNAP Food Benefits — Enter X in the second box and X in the box indicating the SNAP food benefits will be lowered. Enter the old and new benefit levels. Enter the first day of the month, the month and year the decrease will start.
Appointing/continuing a protective payee
Enter X in the first box and X indicating the TANF check requires a protective payee. Enter the first day of the month, the month, and year when the protective payee will be added. When notifying the client after a complete review that the protective payee is being continued, enter the day of the month, the month and the year that the complete review is effective.
TANF — If denying a case, enter X in the third box and X in the box marked TANF on the same line. Enter the last day of the month, the last month, and the year that the client is eligible for assistance.
If denying a case and the family is eligible for post-Medicaid, enter the ending date of this coverage in the Medicaid item on the same line.
SNAP Food Benefits — If denying a case, enter X in the third box and X in the box marked SNAP food benefits on the same line. Enter the last day of the month, the last month and the year the client is eligible to receive benefits.
Denying an application (except for missed appointments in TANF/Medicaid; failure to furnish information in all programs)
If denying an application, enter X in the fourth box and an X in the box on the same line indicating TANF, Medicaid, or SNAP. Indicate on page 3 the reason for denial. Note: If the client is eligible for prior Medicaid, enter X in the fifth box and list the appropriate months.
Denying an application for missed appointments (TANF/Medicaid only) or failure to furnish information
If denying a TANF, Medicaid or SNAP application because of failure to furnish information or a TANF or Medicaid application for failure to keep an appointment, enter X in the sixth box and indicate the effective date of denial. Explain what the client needs to do to have the application reconsidered. If the denial was due to a missed appointment, enter the following after "You still need to: _____."
Add the following comment in the blank, "Call your local office to request another appointment."
Spanish: Enter the following after "Usted todavia tiene que: ______."
Add the following comment in the blank, "Comunicarse con la oficina local para solicitar otra cita."
In the last blank:
- For applications and untimely recertifications, enter the 60th day after the file date for missed appointments and failure to furnish information.
- For timely recertifications, enter the 30th day after the last day of the last benefit month.
- For timely recertifications following a short certification, enter the 60th day after the last full month's benefit issuance date.
Page 3 of Form H1017
Check the box that indicates the reason for the denial.
Credit Report Information
When a credit report obtained by the Texas Works advisor during the eligibility determination process results in fewer benefits than the client otherwise would receive, place an "X" in the Credit Report box. This box is marked in addition to the box indicating the specific reason for denial.
If the reason for denial is either:
- the amount of money you get each month is over the allowed amount, or
- the value of the things you own (resources) goes over the allowed amount;
then in the Comment area, list each household member's name and source of income or resources used in the eligibility determination.
If the reason for denial is not pre-printed on page 3, give a specific explanation of denial. If the reason is:
- failure to provide information, enter the specific information the client did not provide;
- refusal to provide information, enter the specific information the client refused to provide; or
- failure to keep an appointment, indicate the date of the appointment.
- the household was not eligible for the one-time grandparent payment, enter the specific reason:
- the gross income for the household exceeds the income limit;
- the resources exceed the resource limit;
- the household does not meet the relationship requirement; or
- the household has already received the one-time grandparent payment.
- la casa no llenó los requisitos para recibir el Pago Único a Abuelos, porque:
- el ingreso bruto del hogar sobrepasó el límite de ingresos;
- los recursos sobrepasaron el límite de recursos;
- el hogar no llena los requisitos necesarios de parentesco; o
- el hogar ya recibió el Pago Único a Abuelos.
The client messages for SNAP denial codes and TANF reinvestigation and denial codes are listed in C-200, Opening, Denial, and Reinvestigation Codes, as are the client messages corresponding to Medicaid denial codes. Exception: For denials and reductions related to employment services non-compliance, the client messages are listed below.
Message for ESP Noncompliances for TANF and SNAP food benefits — Enter the noncomplying member's name, and complete the client message with the phrase below that indicates the length of the penalty:
(first, second or subsequent noncompliance) "for at least [one] [three] [six] months. The penalty may last longer if this person does not contact our office and agree to comply with the requirements for employment services/voluntary quit."
(first, second or subsequent noncompliance) "por lo menos [uno] [tres] [seis] meses. La sanción puede durar más si esta persona no se comunica con nuestra oficina y se compromete a cumplir con los requisitos en cuanto a servicios de empleo."
Include the specific message from the following list when disqualifying someone or denying a SNAP food benefit case for voluntarily:
- quitting a job, or
- reducing their work hours.
- "Name of client voluntarily quit his most recent job without good cause. To regain eligibility, this person must obtain a comparable job."
"Name of client voluntariamente dejó su trabajo más reciente sin tener motivo justificado. Para volver ser elegible, esta persona tiene que conseguir un trabajo parecido."
- "Name of client voluntarily reduced his work hours to less than 30 hours per week without good cause. To regain eligibility, this person must begin working 30 or more hours per week."
"Name of client voluntariamente redujo sus horas de trabajo a menos de 30 horas por semana sin tener motivo justificado. Para volver a ser elegible, esta persona tiene que trabajar más de 30 horas por semana."
When denying the case because a member failed to attend the Workforce Orientation, use the following special messages:
"Your application is denied because ( name of the required member ) failed to attend the Workforce Orientation."
"Su solicitud ha sido negada porque ____________________ no asistió a la Orientación de la Fuerza Laboral."
Message for OIG Pending District Attorney Cases (PDAC) Notification — Enter the following message in the comments section of the electronic or manual Form H1017 when initiating adverse action to clear an OIG PDAC Notification. Provide the comments in both English and Spanish.
"(Client Name) is disqualified as a fugitive (fleeing to avoid prosecution). When the person is no longer a fugitive, you may request that the person be added to your case."
"(Client Name) ha perdido su elegibilidad por ser fugitivo (por huir para evitar enjuiciamento). Cuando la persona ya no sea fugitivo (ya no esté huyendo para evitar enjuiciamento), usted puede pedir que la persona sea añadida a su caso."
Messages for Notice of Reduced Benefits — If the proposed action lowers the household's benefits for another reason, check the box marked "Other" and enter one of the following messages:
- "Your household income has increased."
"Han aumentado los ingresos de su casa."
- "Your household size has changed."
"Ha cambiado el numero de miembros de su casa."
- "The expenses which this agency can allow as deductions from your income have decreased."
"Han disminuido los gastos que esta agencia puede aceptar como deducciones de los ingresos de su casa."
- "(name) has been disqualified for failing to meet the requirement for:
- providing or applying for a Social Security number,
- working 20 hours per week. To avoid the reduction of denial of benefits, this person must begin working an average of 20 hours per week.
"(name) ha sido descalificado por no satisfacer el requisito de
- tener un número de Seguro Social, o haberlo solicitado,
- trabajar 20 horas por semana. Para evitar la reducción o la Orientación n o la negacion de beneficios, esta persona tiene que comenzar a trabajar un promedio de 20 horas por semana.
- "Your certification period has been extended to enter last benefit mo."
"Su certificacion para beneficios de comida del Programa SNAP se ha extendido hasta enter last benefit mo."
Failure to Provide Information to OIG Due to a Match Report — Add the following message in the comments section when the advisor receives an Action Notice indicating the client failed to provide information to OIG.
"You failed to provide information to the Office of Inspector General. Contact OIG investigator's name at investigator's phone number if you have questions. You may reapply for benefits but will be required to provide the information previously requested."
"Usted no presentó información a la Fiscalía General. Si tiene alguna pregunta, comuníquese con [OIG investigator's name] al [investigator's phone number]. Puede volver a solicitar beneficios, pero tendrá que presentar la información que se le pidió anteriormente."