- To provide the income assistance office with a record of case actions.
- To provide the income assistance supervisor with a source for selecting cases to read.
- To monitor caseloads.
When to Prepare
Clerical staff make individual entries for each case when it is processed.
Number of Copies
The clerical staff complete an original and one copy for each worker.
The clerical staff keep the original and give the copy to the worker.
Staff keep Form H1041 for as long as it is useful.
Enter at the top of the form the worker's name, unit number, and the period of time covered by the report.
Date, Case Name, Category, Case No. — Self-explanatory.
Type of Action — Enter the three-digit code given on Form H1000-A/B which describes the type of action.
Decision — Check the column describing the decision. The columns are coded:
R — Raised grant
L — Lowered grant
S — Sustained
G — Granted or Certified
D — Denied
The columns without headings are reserved for local use.