Form H1073, Personal Responsibility Agreement

Instructions for Opening a Form

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Effective Date: 4/2014


Updated: 9/2003


  • To provide advisors with a standardized summary to inform applicants and recipients of their responsibilities as participants in the TANF (TP 01, 61) program.
  • To emphasize with recipients the message of individual responsibility and self-sufficiency.


When to Prepare

Form H1073 must be signed by:

  • caretakers (SIG 8) and second parents (SIG 7) who receive TANF [including teen parents that are caretakers] at initial interviews or at subsequent interviews if a signed form is not already on file or there has been a break in certification,
  • payees and disqualified parents if a signed form is not already or file or there has been a break certification, and
  • the advisors.


  • If the second parent is in the home, he must sign a separate form.
  • If the caretaker, second parent, payee or disqualified adult refuses to sign Form H1073, deny the case.

Number of Copies

File the original Form H1073 under "Legal" in the case record and give a copy to the client.

Detailed Instructions

What are Your Responsibilities?

Refer to Texas Works Handbook Section A-2100. Explain each responsibility and the related penalties to each client and HHSC's responsibilities to provide support service.

Information on Additional Penalties

Continue to provide clients with Form H1712, Explanation of Child/Medical Support, Family Violence and Good Cause, and Form H2580, TANF Employment Services Notice.