Form H3080, Notification of Eligibility - Qualifying Individuals Program

Instructions

Updated: 1/2003

Purpose

• To notify the client of his eligibility status as a Qualifying Individual (QI).
• To notify the client or the responsible party of the right to appeal.

Procedure

When to Prepare

Prepare Form H3080 when a decision is made about the client's eligibility for QI.

Number of Copies

Prepare the original and two copies.

Transmittal

Send the original and first copy to the client at his address or that of his responsible party. Enclose a prepaid return envelope. File the second copy in the case record.

Form Retention

Keep the copy according to the retention requirements of the case record.

Detailed Instructions

This form may be typed or legibly handwritten.

Inside Address — Enter the name of the client and his mailing address or that of his responsible party.

Date — Self-explanatory.

Worker — Self-explanatory.

Office Address and Telephone Number — Enter the caseworker's complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.

I have determined that ... — Check the appropriate box to indicate whether the client is eligible as a QI.

You are eligible to receive benefits under the Qualifying Individuals-1 (QI-1) program beginning ... — If this box is checked, enter the effective date of QI-1 benefits. This date may be up to three calendar months prior to the month in which the application was filed, if all criteria are met.

You are eligible to receive benefits under the Qualifying Individuals-1 (QI-1) program beginning ... through ... — If this box is checked, enter the beginning and ending dates of QI-1 benefits. These dates indicate open/close eligibility for the QI-1 program.

Page 2: Worker, Mail Code, Office Address, and Telephone Number — Enter the caseworker's name, mail code, complete office address, and telephone number. Include the TDD telephone number if the office is equipped with TDD.