PURPOSE

• To serve as a written notice to clients or their representatives that their benefits have been forfeited and will be or have been denied as a result of failure to cooperate with the PRA.
• To tell clients how to have their benefits reinstated.

PROCEDURE

Attach Form H1017-P to Form H1017 when the household is determined to not be cooperating with the PRA requirements.

Number of Copies

An original and one copy.

Transmittal

Give or mail the original to the client. File one copy in the case record under legal.

Form Retention

See the requirement in the Manager's Guide for Eligibility Programs.

DETAILED INSTRUCTIONS

1. Check the box on Page 1 of Form H1017:

   "You will not be eligible for"

   TANF after __________
   Medicaid after __________ (enter denial date)

2. In the comment section on Page 3 of Form H1017, enter "See attached Form H1017-P."
3. Enter the first noncompliance month in the blank provided.
4. Check the appropriate section. If the noncooperation is discovered, receive date on the CSNC online system or the noncooperation date for Choices is in the first month of noncooperation, mark the box for Section I. If the noncooperation is discovered, receive date on the CSNC online system or the noncooperation date for Choices is in the second month of noncooperation, mark the box for Section II.
5. Section I: Enter the first forfeit month. Enter the second month of noncooperation.

   Section II: Enter the second forfeit month.

6. Check the appropriate noncooperation box and enter the name of the applicable household member(s).