Information gathered by the AIS is automatically printed on HFS 1376C. To complete HFS 1376, review the case record and enter verified information in pencil.
AIS enters the name of the payee for the benefit unit. Enter the name of the payee, if completing the form manually.
AIS enters the category, office number, group, and basic number. Enter this information if completing the form manually.
This field appears only on HFS 1376C. It contains the following information:
From information gathered in AIS, shows the last and first names of the person(s) getting aid in this case.
If entering information manually, enter the name(s) of the person(s) in the assistance unit.
If a member is later deleted, draw a line through the entry and make a notation "Deleted effective (date)."
This field contains the relationship of the assistance unit member to the person listed on AIS line one. When there is more than one case in a unit, relationship only prints on the primary case. This field does not print for the alternate cases in the uni
When completing the form manually (for AFDC only), enter the abbreviation that shows the relationship between the payee to each member of the assistance unit:
LF -Legal Father (Adjudicated Father)
PF - Putative Father
M - Mother
SF - Stepfather
SM - Stepmother
GF - Grandfather
GM - Grandmother
GGF - Great Grandfather
GGM -Great Grandmother
B - Bother
S - Sister
N - Niece or Nephew
SP - Spouse
U - Uncle
A - Aunt
C - Cousin
OTHER - Please indicate
This field contains the SSN that corresponds to the person line.
If completing the form manually, enter the client's SSN.
This field appears only on the HFS 1376C. It contains the birth certificate number or proof used to establish identity/relationship.
This field appears only on the HFS 1376. Manually enter the date of marriage or divorce, name of person, and document used to verify the marriage or divorce.
Complete this field manually. Enter the language preference indicated by the client and/or assistance unit members according to the AIS preference or Quinones procedures.
AIS enters the first and last name of the absent responsible relative(s), if known. If completing manually, enter the absent responsible relative(s)' name.
S - Son
D - Daughter
GS - Grandson
GD - Granddaughter
P - Putative Father
F - Friend
O - Other
Enter the birth date (month, day, and year), if known.
If known, enter the amount and frequency of each person's contribution to the assistance unit.
If the person(s) who is not a member of the assistance unit has an active Healthcare and Family Services case (including FS), enter the ID number. If none, mark N/A or leave blank.
This field shows the current address of the client. It does not provide information about previous addresses.
When completing this information manually, enter the current address of the assistance unit, and the month/year the client moved to it.
This field lists the client's, or other unit member's, phone number at the current address.
When entering this information manually, enter the client's phone number. If the client has no phone, enter a phone number where they can be reached.
These fields contains the first name of the child(ren) in the case attending school, the name of the school(s) that the child(ren) attends, and the grade for the child(ren) in school, as entered in AIS.
When completing the information manually, enter one of the following codes to describe a unit member's school attendance:
F - Attends school full-time
P - Attends school part-time
N - Does not attend school
Use this area to list the name of an emergency contact person for the unit. List the emergency contact's phone number and address.
Note any medical problems or information relevant to the case.
Pers (HFS 1376C) - Enter the line number of the person(s) with any known special medical needs.
AIS enters the Item 91 code on HFS 1376C, for the verified assets or resources of each person in the case. AIS also shows the name of the first listed owner of the asset/resource.
When completing this information manually, next to the asset list the person(s) owning the asset. Indicate whether the asset is exempt or nonexempt, the location of the asset and, if applicable, enter the fair market/equity value. When completing this information manually, list the forms completed and the date completed.
Complete this section manually to record the location and value of assets. Also record information that can help handle a case better. For example:
Enter the date of the last food stamp replacement.
Enter the date, amount, and type of aid issued under the Crisis Assistance Program.
NOTE: After approval, HFS 1376C information cannot be changed in AIS. However, if the HFS 1376C printed at approval gets lost or misplaced and the AIS record is still on file, reprint one from the Forms Subsystem Menu.
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