Form H1901, TIERS Data Collection Worksheet

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H1901.pdf (101.83 KB)

Effective Date: 10/2010


Word: H1901.doc


Updated: 10/2010


  • To record documentation and verifications obtained during the application/redetermination interview when TIERS is unavailable or in "Read Only."
  • To record computations and determine eligibility and allotment for SNAP expedited benefits.


Advisors complete one copy of Form H1901 when the advisor is unable to make entries in TIERS.

Form Retention

Form H1901 must be retained until the information is entered into TIERS when the system is available. It may be destroyed after entry. Imaging is not required.

Detailed Instructions

Form H1901 is to be used in conjunction with any version of the H1010 during the interview (when the application is available). Entries that are on the H1010, such as household member's name, date of birth, Social Security number, etc., are not required to be on Form H1901. Staff can enter "refer to application" as appropriate. Space to record Case Comments documentation has been included after most sections. Entries are not needed for sections that are not applicable to the program being worked.

Section I — Basic Information


Section II — Individual Information

Self-explanatory. In the Case Comments space provided, give a brief description of the household's circumstances.

Section III — Relationship


Section IV — Education

This section includes entries for school attendance (PRA and ESP information) and enrollment in higher education.

Section V — Living Arrangement


Section VI — Individual Demographics

This section includes entries for ID verification, citizenship, alien status, information if the applicant has moved from another state, benefits received in another state, verification of physical address, etc.

Section VII — Individual Questions

This section includes entries for household members who are disabled, foster care children, newborns or pregnant.

Section VIII — Non-Financial Questions

This section includes the Non-Financial questions for TANF (PRA signed, pended for Workforce Orientation, etc.). It also includes information to determine ABAWD and finger imaging status.

Section IX — Absent Parent Information


Section X — Resources


Section XI — Income


Section XII — Deductions


Section XIII — Streamlined Reporting


Section XIV - Management

This section includes space to document the applicant's explanation of past, present and future management when management is negative or questionable.

Section XV - Form H1801, SNAP Budget Worksheet

The SNAP budget worksheet is included on the last page to determine eligibility for expedited benefits.