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Effective Date: 



Updated: 1/2012


  • To serve as documentation that the family violence option and good cause were discussed with the client.
  • To document the assessment and referral if a client requests the family violence option.
  • To report final determination of good cause.


When to Prepare

The advisor prepares Form H1713 at each application.

Part I, Acknowledgement — The client reads and signs acknowledging that information about the family violence option and good cause was shared. Discuss and offer the family violence option at each periodic review; however, a signature is only required once. If the client refuses to sign, use the comment section to document. If the client claims good cause and good cause is approved, the advisor must re-evaluate the good cause status at subsequent reviews.

Part II, Assessment Referral — The advisor completes if the client claims good cause for noncooperation as a result of family violence.

Part III, Report of Good Cause — The advisor completes when good cause is approved and uses this section to report the final determination to state office and the local child support unit.

Number of Copies Send the second copy to the local child support unit.

Filing Instructions

File the original under the Child Support tab.

Form Retention

Refer to the Texas Works Manager's Guide for form retention information.

Detailed Instructions