Leave this item blank for SNAP Only (Category 08) cases.

Ending Medical Eligibility Date applies only to All Kids Assist and Moms & Babies (Categories 94 and 96) cases when using a TA 10. Enter the last day of the last month of medical eligibility.

revised textDate of Death applies only to RRA (Categories 00 and 90); AABD (Categories 01, 02, 03, 91, 92, and 93); and one person TANF or FHP cases (Categories 04, 06, 94 and 96) when canceling using TA 22 with TAR 00. Enter the date of death of the customer.

Enter the date (month, day, and year) as 2-digit numbers. For example, enter January 1, 2009, as:  01 01 09