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 notify the client of his eligibility status as a Qualifying Individual (QI).
- To notify the client or the responsible party of the right to appeal.
When to Prepare
Prepare Form H3080 when a decision is made about the client's eligibility for QI.
Number of Copies
Prepare the original and two copies.
Send the original and first copy to the client at his address or that of his responsible party. Enclose a prepaid return envelope. File the second copy in the case record.
Keep the copy according to the retention requirements of the case record.
This form may be typed or legibly handwritten.
Inside Address — Enter the name of the client and his mailing address or that of his responsible party.
Date — Self-explanatory.
Worker — Self-explanatory.
Office Address and Telephone Number — Enter the caseworker's complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.
I have determined that ... — Check the appropriate box to indicate whether the client is eligible as a QI.
You are eligible to receive benefits under the Qualifying Individuals-1 (QI-1) program beginning ... — If this box is checked, enter the effective date of QI-1 benefits. This date may be up to three calendar months prior to the month in which the application was filed, if all criteria are met.
You are eligible to receive benefits under the Qualifying Individuals-1 (QI-1) program beginning ... through ... — If this box is checked, enter the beginning and ending dates of QI-1 benefits. These dates indicate open/close eligibility for the QI-1 program.
Page 2: Worker, Mail Code, Office Address, and Telephone Number — Enter the caseworker's name, mail code, complete office address, and telephone number. Include the TDD telephone number if the office is equipped with TDD.