Form H1017-P, Notice of Benefit Denial and Personal Responsibility Agreement (PRA) Reasons

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Effective Date: 8/2023


Updated: 8/2023


  • To serve as a written notice to Temporary Assistance for Needy Families (TANF) recipients or their representatives that their benefits have been forfeited and will be or have been denied as a result of failure to cooperate with the PRA.
  • To tell TANF recipients how to have their benefits reinstated.


Attach Form H1017-P to Form H1017, Notice of Benefit Denial or Reduction, when it is determined the household is not cooperating with PRA requirements.

Number of Copies

An original and one copy.


Give or mail the original to the person. Scan and file a copy in the electronic case record.

Detailed Instructions

HHSC staff follow the steps below when completing the H1017-P:

  1. Check the box on Page 1 of Form H1017:

    "You will not be eligible for"

    TANF after __________ (enter denial date)
    Medicaid after __________ (enter denial date)
  2. In the comment section on Page 3 of Form H1017, enter "See attached Form H1017-P."
  3. Complete the H1017-P.

Part I 

Noncooperation Month — Enter the first noncompliance month in the blank provided.

Part II

Forfeit Month — Check the appropriate box. 

First Month of Forfeit — Enter the first forfeit month and the second month of noncooperation.

Second Month of Forfeit — Enter the second forfeit month.

Part III

Noncooperation Reason — Check the appropriate noncooperation box and enter the name of the applicable household member(s).