WAG 26-02-01-a: How to Complete the Form 360 Series

  1. Complete only those sections, items, and pages which are relevant to each application. Do not complete all sections and do not send all 10 pages to the client.
  2. Always send the first page (Form 360D) and the rights and responsibilities and appeals rights page(s) (Form 360P and/or Form 360Q).
  3. Always complete the following on Form 360D:
    • date of notice;
    • Family Community Resource Center name, address, and telephone number; and
    • date of application. 

    NOTE: Do not date Form 360D until the decision is made on the application. Enter, as the date of the notice, the date Form 360D is mailed. 

  4. Complete and send all other pages and sections of Form 360 series that apply to the assistance program(s) for which a decision was made.

    NOTE: For TANF clients who will not receive a centrally issued Form 360C, you must also complete and mail clients:

    • Worksheet for Computation of Grant Amount (Form 553F); and, if applicable,
    • Attachment to Form 553F - Worksheet for Computation of Grant/SNAP (Form 553G).

    Keep copies of the Form 360, Form 553F, and Form 553G in the case record. 

Approved Cash and/or Medical (Form 360D and Form 360E)

Enter information regarding cash benefit amount and beginning eligibility date in the designated areas.

text revisedComplete this section when some persons in the original application are approved for cash and others are approved for medical under the same program determination, such as 03, 04, 93, or 94.

If more than one unit is approved for Cash, complete a separate Form 360D page for each unit and repeat this section. (If necessary, complete Form 360E.) If the decision on the original Cash request results in the approval of aid under more than one category, such as 03, 04, or 94R, establish separate case records for each approved category of aid. Send one Form 360D to notify the applicant of the types of aid approved.

Do not complete this section if the application is for SNAP benfits only. Use the SNAP sections for SNAP decisions.

List the first and last names of each person(s) approved for benefits, each person's RIN, caseload number, and case ID number. Approve aid under the appropriate category of aid. Show in the approved categories of aid in this section. Send one approval notice.

Print information about the benefit amount and beginning date for medical eligibility.

text revisedIf the applicant is found ineligible for AABD or TANF, decide eligibility for 94R for children

NOTE: In the Denied - Cash and/or Medical Assistance section, enter the denial reason for each program determination made.

Medical Backdate (Form 360F, Form 360G, and Form 360H)

Complete this section only if there is at least one person in the approved case who does not receive medical backdate coverage and the client has requested medical backdate coverage.

NOTE: Do not complete this section if everyone in the case is eligible for backdated coverage. When everyone in the case is eligible for backdated coverage, enter the beginning medical eligibility date in Approved Cash and/or Medical Section.

When a locally issued Form 360 series is sent, do not attach a locally issued Backdate Supplement to Notice of Decision on Application for Assistance Grant (Form 360B).

Check Item 1 if the client does not want the Department to consider medical backdate.

Check Item 2 if the client asked for medical backdate coverage.

text revisedWhen a client is ineligible for TANF or AABD Cash or Medical for nonfinancial reasons, make a decision on Medicaid eligibility (regular Medical) for the backdate period. Consider each person's eligibility for the full 3-month medical backdate period unless the client declined backdating.

In Item 3, enter the names of persons eligible for medical backdate for any or all of the 3 backdate monthstext deleted and identify the eligible months.

In Item 4, enter the names of persons ineligible for medical backdate, the months ineligible for medical backdate, and the reason for ineligibility. The reason will be nonfinancial. Use the same denial TAR messages that are valid with TAR 05, to tell the client why they are not eligible for the medical backdate.

Example 1:

Mary applied for Medical in 03/00. She is eligible for AABD Medical starting 03/00, but is ineligible for AABD Medical backdate. Complete the "Medical Backdate" section as follows:

We have not authorized retroactive medical assistance coverage for Mary under the Medicaid program for 12/99, 01/00, 02/00 because "You do not meet Department definition of disabled. If you wish to get more information about the reason for this decision, contact the local DHS office." Policy Reference***PM 03-08

Ineligible Persons (Form 360H)

Use this section to identify the persons who were ineligible to be included in the unit with those listed in the "Approved Cash and/or Medical" section. Use this section to identify persons who are excluded for medical in a Cash case or for persons excluded for cash in a Cash case.

Enter the appropriate denial reason message and corresponding policy reference for each person in this section.


If the cash applicant does not cooperate regarding medical support rights, eligibility exists for cash only. The person is not eligible for medical. Print the following statement at the end of this section:

(Name of person) is not eligible for medical assistance because they did not cooperate regarding medical support rights. Policy Reference***PM 03-19

Denied - Cash and/or Medical Assistance (Form 360I)

Complete this section when all persons on the application are denied for the cash or medical programs for which they applied. Since all persons are being denied, use only one denial reason per program.

Complete this section if the applicant is determined ineligible for Cash, but is approved for Medical. Enter the denial reason for the cash decision.

If, based on nonexempt income and/or excess nonexempt assets, the case would result in a spenddown and the client wants to enroll in spenddown, enter the reason for cash ineligibility and attach Notice of Decision on Application (MANG) for a MediPlan Card (Form 458SP) telling the client of their enrollment for spenddown.


A person applied for Cash and is ineligible for cash because of a nonfinancial reason. The applicant is approved for Medical. Enter a denial reason for the Cash decision, on the Medical approval notice.

Pending SNAP (Form 360J)

Complete this section to tell a SANP applicant, by the 30th day, that the SNAP application is still being processed (or pended).

Approved SNAP (Form 360J)

Complete this section when one or more persons on the original SNAP application are approved for non-expedited SNAP benefits.

Enter information about prorated benefits, regular benefits, and last month of the approval period. If the client is being approved only for the regular roll, complete only the last sentence in the 2nd paragraph.

If more than one SNAP unit is approved for SNAP, complete another page for each unit.

Expedited SNAP (Form 360K)

Use this section when expedited SNAP benefits are issued.

It identifies the persons included in the approval, the amount of the expedited issuance, the period for which it was issued, and a list of any postponed verifications.

If the application was made after the 15th day of the previous fiscal month, complete the last paragraph in this section about the 2nd month's benefits.

Notice of Expiration of Certification Period (Form 360M)

Complete this section only when SNAP benefits are approved by mercury rolls. This section is used to tell the SNAP unit of the last date of the SNAP approval period and the last date that the SNAP unit must make reapplication to ensure uninterrupted SNAP benefits. Also, an optional entry may be made for scheduling a client appointment.

Ineligible Persons (Form 360N)

This section identifies persons who were ineligible to be included in the approved SNAP case. For example, this section is used to identify persons who are ineligible for SNAP due to the SSN requirement, citizen/INS status, and persons disqualified due to Intentional Program Violation.

Denied SNAP (Form 360N)

Complete this section when all applicants in the SNAP unit are denied SNAP benefits. If more than one unit is ineligible for SNAP, repeat this section and enter the SNAP denial reason.