Form H1706, Good Cause Recommendation and Family Violence Exemption

Instructions for Opening a Form

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Effective Date
08/2015
H1706.pdf (109.94 KB)

Instructions

Updated: 4/2022

Purpose

  • To serve as verification that a person requesting Temporary Assistance for Needy Families (TANF) or medical programs has contacted a family violence specialist for a good cause recommendation for the family violence exemption.
  • To communicate whether the family violence specialist does or does not recommend good cause.

Procedure

When to Prepare

The family violence specialist completes the form indicating that an assessment has been made and if  the family violence specialist recommends good cause for the family violence exemption.

The family violence specialist completes and sends the form to the person applying for or receiving benefits or to HHSC within five days of the assessment.

Number of Copies

Complete an original only.

Filing Instructions

Add an electronic copy to the case record.

Transmittal

Give the client the original with the top portion completed by HHSC staff.

Detailed Instructions

Client Name — Enter the name of the person requesting good cause based on family violence for non-complying with TANF and medical programs absent parent information requirements.

Case Name (if different) — Enter the case name as it appears in TIERS if it is not the same person requesting good cause. 

Case Number — Enter the TIERS case number.

To Texas Works Advisor — HHSC staff enter the eligibility staff person’s name who the family violence specialist should contact for questions .
 
Texas Works Supervisor — HHSC staff enter the eligibility staff person’s supervisor.

To be completed by the family violence specialist

Date — The family violence specialist enters the date of the interview with the client about family violence.

The family violence specialist marks one of the following two check boxes

  • Recommend HHSC grant a good cause waiver and the family violence exemption — If the family violence specialist’s assessment is that the person should receive the good cause exemption, they will check this box. 
  • Do not recommend HHSC grant a good cause waiver and the family violence exemption because — If the family violence specialist’s assessment is that the person should not receive the good cause exemption, they will check this box and include the reason why they do not recommend good cause.

Signature — The family violence specialist signs the form. 

Printed Name — The family violence specialist prints their name.

Telephone No. — The family violence specialist includes their phone number.