WAG 26-01-01-a: How To Complete HFS 1376/HFS 1376C

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.

Case Name - Payee

AIS enters the name of the payee for the benefit unit. Enter the name of the payee, if completing the form manually.

Case ID Number

AIS enters the category, office number, group, and basic number. Enter this information if completing the form manually.

Intake Caseload ID/Field Caseload

This field appears only on HFS 1376C. It contains the following information:

  • the intake caseload designation for the eligibility worker, and
  • the field (IM) caseload to which the approved case was assigned.

Assistance Unit

  • Last Name  First

    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)." 

  • Rel

    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

  • SS Number

    This field contains the SSN that corresponds to the person line.

    If completing the form manually, enter the client's SSN. 

  • BC/Identity Verification (HFS 1376C)

    This field appears only on the HFS 1376C. It contains the birth certificate number or proof used to establish identity/relationship. 

  • Marr/Divorce Information(HFS 1376)

    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. 

  • Language

    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. 

  • Absent Res Rel (HFS 1376C)/Responsible Relative (HFS 1376)

    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. 

  • Others in Household
    • Last Name  First -This field contains the last name and first name of other person(s) in the unit. Enter information manually, when necessary.
    • Rel -This field tells the relationship of the other person(s) to the benefit unit payee. If the case is an alternate case these codes do not print. If entering this information manually, enter the abbreviation that shows the relationship between each person living in the home who is not in the assistance unit, and the payee.

S - Son

D - Daughter

GS - Grandson

GD - Granddaughter

N - Niece or Nephew

P - Putative Father

F - Friend

O - Other

    • Income Type (HFS 1376C)/Income (HFS 1376) - Lists the first source of income for the other person(s) in the home. Enter manually, when necessary.
  • Birth Date (HFS 1376)

    Enter the birth date (month, day, and year), if known. 

  • Paid to Client (HFS 1376)

    If known, enter the amount and frequency of each person's contribution to the assistance unit. 

  • Case ID Number (If Active) (HFS 1376)

    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. 

  • Address (HFS 1376C)/Address of Client (HFS 1376)

    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. 

  • Phone

    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. 

  • School Attendance (HFS 1376C)/School Status (HFS 1376)

    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 

  • Emergency Contact Name (HFS 1376C)/Contact in Emergency (HFS 1376)

    Use this area to list the name of an emergency contact person for the unit. List the emergency contact's phone number and address. 

  • Special Medical Needs

    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. 

  • Assets/Resources

    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. 

  • Special Notes by Caseworker (HFS 1376C)

    Complete this section manually to record the location and value of assets. Also record information that can help handle a case better. For example:

  • postponed eligibility factors at intake,
  • health insurance information that's needed to complete HFS 1442, Health Insurance Report, or
  • a client with problems in getting verifications or understanding what is needed.
  • F.S. Replacements (HFS 1376)

    Enter the date of the last food stamp replacement. 

  • Crisis Assistance (HFS 1376)

    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.