Form H1103, Verification of TANF Eligibility

Instructions for Opening a Form

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Effective Date
01/2022
H1103.pdf (112.66 KB)
H1103-S.pdf (113.24 KB)

Instructions

Updated: 1/2022

Purpose

To provide eligibility staff a form for recording verification of:

  • case and relationship information from a TANF child's birth, hospital, or baptismal certificate; or
  • age and place of birth when a caretaker or second parent is applying for a Social Security number.

Procedure

When to Prepare

Complete Form H1103 when a person initially applies or adds a child to the certified group, or a caretaker or second parent applies for a Social Security number.

Instead of Form H1103, a readable photostatic copy of the document used to verify age and relationship may be imaged in the case record.

Number of Copies

  • Complete one section of one copy of Form H1103 for each certified child in the household.
  • Complete one section of the form if proof of age, relationship, and citizenship are necessary for a client to obtain a Social Security number for a caretaker or second parent such as aunt, stepfather and grandmother.

Detailed Instructions

A copy of the birth certificate is required to verify eligibility of each child in the TANF program. Acceptable copies are those of certificates filed in the Bureau of Vital Statistics or the county of birth in the United States or a copy of the birth certificate registered in a foreign country.

If a birth certificate is not available, use a hospital or baptismal certificate as verification. Use only documents that include all the facts to fully establish the date of birth and the relationship of the child to the TANF caretaker.

If the necessary information about age and place of birth of the caretaker or second parent is not available from the child's birth record, use a child information section of the Form H1103 to enter the information from the caretaker's or second parent's proof of birth.

If proof of birth is not available, an evaluative conclusion must be established as described in the detailed instructions below.

Complete each item that applies for each child. The same form may be used for up to four children. If there are more than four children, use an additional Form H1103.

Case Name — Enter the case name.

Address — Enter the household's address.

Application or Case No. — Enter the application or case number.

Name of Child — Enter the name of the child as shown on the birth, hospital, or baptismal certificate.

Relationship to Payee — Enter the relationship of the child to the caretaker or second parent.

Gender — Enter M or F.

Date of Birth — Enter the child's date of birth as shown on the document.

Name of Child on Form H1010 — Enter the name of the child as shown on Form H1010.

City and State of Birth — Enter the child's place of birth as shown on the document.

Document Reviewed — Check the box to indicate the type of document viewed.

If proof of birth for a child is not available make an evaluative conclusion about the child’s age and relationship following policy in TWH A-523.1, How to Make an Evaluative Conclusion. If an evaluative conclusion is made, enter any details, charts of relationship, or any other pertinent information on the back of the form. The supervisor must sign the form to show concurrence with the evaluative conclusion. Ensure both sides of the form are imaged into the case record.

Does payee have document? — Check the box that indicates if the caretaker or second parent has the document in their possession.

Mother's Name as Shown on Document — Enter the name of the child's mother, as shown on the document.

Age — Enter the age of the child's mother when the child was born, as shown on the document.

City and State of Birth — Enter the place where the child's mother was born, as shown on the document.

Father's Name as Shown on Document — Enter the name of the child's father, as shown on the document. If there is no father named, enter "none named."

Age — Enter the age of the child's father when the child was born, as shown on the document.

City and State of Birth — Enter the place where the child's father was born, as shown on the document.

Name of Hospital or Church — Enter the name of the hospital from a hospital certificate or the name of the church from a baptismal certificate.

File or Certificate No. — Enter the file or certificate number from the birth, hospital, or baptismal certificate.

Page — Enter the page number where the birth certificate is found at the Bureau of Vital Statistics.

Volume — Enter the volume where the birth certificate is found at the Bureau of Vital Statistics.

City, County, State — Enter the city, county, and state where the record is filed.

Signature – Advisor and Date Signed — Sign the completed section of the Form H1103 and enter the date signed.