- To document verification and clarification of issues involved in special reviews and to make budget adjustments.
- To document and budget denied cases that do not require completion of Form H1101.
Note: Do not use Form H1102 to certify an applicant or to complete a periodic review if eligibility is continued.
When to Prepare
Use Form H1102 when a change occurs that requires a special review or a change in budget entries. Use Form H1102 for denials if information on the Form H1010-B or provided by the client proves ineligibility.
Note: Complete Form H1100, Addendum Income Worksheet, if the case involved applied income, diverted income, or lump sum payments. Attach Form H1100 to Form H1102.
Number of Copies and Transmittal
Complete one copy of Form H1102 in ink. File the form behind the corresponding Form H1010-B or on the top right side of the case record.
See the Manager's Guide for Eligibility Programs for the retention requirement.
Most of Form H1102 is self-explanatory. Detailed instructions are provided for those items and sections that need clarification.
STEP 1 — Certified Group Earned/Unearned Income.
Note: If income is counted for eligibility and disregarded for benefits, the advisor may have to complete a separate worksheet.
Line 1 – Names — Enter the first and last name initials of each client with countable income. If more than two members have income, enter the remaining member's income in the third column as "others" and identify them in the documentation section.
Line 2 – Total Gross Earned — Enter the amount of gross income for each client. Do not include EIC income. Also enter each client's amount in Item 42-B, Form H1000-A/B/C. Enter the total earnings in the far right box.
Line 3 – RSDI — Enter any RSDI received. Also enter each client's RSDI amount in Item 43, Form H1000-A/B/C.
Line 4 – Pensions, VA, and Unemployment Benefits — Enter any of these benefits received. Also enter each client's benefits in Item 44, Form H1000-A/B/C and the associated code in Item 42-A.
Line 5 – Railroad Retirement — Enter any railroad retirement benefits received. Also enter the family's total amount in Item 55, Form H1000-A/B/C.
Line 6 – Subtotal — Enter the total of lines 3, 4, and 5.
Line 7 – Cash Contributions — Enter the countable amount of any cash gifts or contributions received.
Line 8 – Other Income — If client has unearned income other than a type identified elsewhere in Step 1, enter the amount received(examples: stock dividends, interest income).
Line 9 – Applied Income of Legal Parent Disqualified for Citizenship — Enter the amount of applied income from Form H1100, Step 1, line 9.
Line 10 – Applied Income of Stepparent or Alien Sponsor — Enter the applied income from Form H1100, Step 2, line 10 or from Step 4, line 9.
Line 11 – Subtotal — Enter the total of lines 7, 8, 9, and 10.
Line 12 – Child Support — Enter the total monthly child support received for each person. Enter only for
- initial applications;
- ongoing cases for which Form H1714, H1715, H1716, orH1717 is received; or
- ongoing cases in which child support is counted because of failure to remit.
Line 13 – Minus Child Support Disregard — For situation A listed for line 10 above — Enter $50 or the actual amount of total child support if less.
Do not enter a disregard amount for situation 10-B or 10-C above.
Line 14 – Net Countable Child Support — Subtract line 11 from line 10 and enter the remainder.
Line 15 – Total — Enter the total of the amounts from boxes C and D, then enter the total from line 15 in item 56, Other Income, on Form H1000-A/B.
Note: When child support must be counted because of failure to remit, add the gross amount to line 15 for inclusion on Form H1000-A/B, Item 56, Other Income.
STEP 2 — Earned Income Deductions.
Enter the standard work-related expense (not to exceed the member's monthly earned income) for each certified member who has countable earnings. Enter the certified group's total deduction in the right column. Enter each member's allowable costs for dependent care (up to the maximum). Enter the total in the right column.
STEP 3 — Budgetary (100%) Needs Test.
(Leave blank for cases that are active or have been active in the last four months.) Follow the instructions printed on the form. If the unmet need on line 9 is 50 cents or more, proceed to Step 5 after documenting the first month of eligibility for earned income deductions for anyone with earned income.
Note: If there is a diversion amount entered on Form H1100, Step 3, and someone other than the individual with diversions has countable income (or two members with joint diversions both have countable income) to be entered on Form H1101, compute each member's income/earned income deductions on separate Forms H1101 until after subtracting the actual amount allowed to be diverted from each individual's income. Then add their total net incomes on one form in line 8.
When two members have joint diversions, any amount of the diversion that exceeds one member's income can then be diverted from the other member's income.
STEP 4 — Recognizable Needs Test.
Complete Step 4 to determine eligibility for all applicants who passed Step 3 and for all households currently certified for TANF.
Follow instructions on the form.
Complete line 5 a only in Part A for applicants with earned income who have not been a client in the last four months. Complete line 5 b for applicants that pass Part A and all other clients. If the client is not eligible for the deduction, or declines use of it, proceed to line 6. Note: Each client may be eligible for the 90% earned income deduction, up to a maximum of $1400. If more than one client is eligible for the deduction, enter the total deduction for all eligible clients.
Note: If there is a diversion amount entered on Form H1100, Step 3, and someone other than the individual with diversions has countable income (or two members with joint diversions both have countable income) to be entered on Form H1101, compute each member's income/earned income deductions on separate Forms H1101 until after subtracting the actual amount allowed to be diverted from each individual's income. Then total their adjusted gross incomes on one form in line 13.
When two members have joint diversions, any amount of the diversion that exceeds one member's income can then be diverted form the other member's income.
Total Deductions: Form H1000-A/B/C Entry, Item 58 — Compute the amount of deductions for entry in Form H1000-A/B/C, Item 58, Deductions, by adding the standard work-related expense deduction and any amounts diverted from income of a certified member or status-in-group 0 disqualified legal parent.
Note: For each household member, his deductions entered here cannot exceed his total income. This also applies when there is more than one household member with earnings and/or diverted income.
STEP 5 — Grant Calculation.
Complete Step 5 to determine the TANF grant amount if the household has an unmet need of at least $.01 on line 14 of Step 4.
Use the maximum grant figure from the TANF Budgetary Allowance chart for the household size and composition.
Follow instructions on form.