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201.10 TANF MANUAL 7/24 Page 4b

A signed copy of the "Notice of Cooperation and Good Cause” shall be filed in the case record and a duplicate copy will be given to the applicant/recipient. If the applicant/recipient wishes to change the claim subsequent to signing one "Notice of Cooperation and Good Cause" then he must sign another form indicating the change of claim. Otherwise, only one "Notice of Cooperation and Good Cause" is necessary per case record unless the case is closed and another application is made subsequently. Because the notice outlines the rights and responsibilities of the applicant/recipient, the eligibility worker shall review each condition with the applicant/recipient to assure a complete understanding. The agency must also advise the applicant/recipient that if a finding is made that no good cause for not cooperating exists, cooperation will be required.

Note: When a minor parent is receiving assistance for her child in the unit with her parent, the good cause provision may also apply to the minor parent. The minor parent must sign a separate "Notice of Cooperation and Good Cause."

D. Acceptable Evidence to Substantiate Good Cause Claim - Each applicant or recipient who claims to have a good cause for not cooperating must provide acceptable evidence, or provide sufficient information to permit an investigation to determine if good cause exists. The applicant/recipient must provide the evidence within twenty (20) days from the day he makes the good cause claim or the agency will determine that good cause does not exist. The agency must base the determination of good cause on evidence provided by the applicant or recipient and/or through an investigation by the agency.

The agency will determine that good cause exists when the information obtained provides evidence of good cause for not cooperating. The following specified evidence will be sufficient to determine the existence of the good cause claimed circumstance.

1. Incest or Rape - Birth certificates or court, medical, criminal, child protective services, social services, or law enforcement records which indicate that the child was conceived as the result of incest or rape;

2. Adoption - Court documents or other records which indicate that legal proceedings for adoption are pending before a court of competent jurisdiction or a public or licensed private adoption agency is currently assisting the applicant/recipient to place the child for adoption and such discussions have not gone on for more than three months. The agency must obtain a written statement from the adoption agency.

3. Physical or Emotional Harm - Court, medical, criminal, child protective services, social services, psychological, law enforcement records, sworn statements from individuals other than the applicant or recipient with knowledge of the circumstances which provide the basis for the good cause claim, or a written statement from a domestic violence services program or sexual assault crisis center professional indicating that the putative father or noncustodial parent might inflict physical or emotional harm on the child or caretaker-relative. Expired or outdated court/legal documents and police reports are acceptable evidence to be used in the evaluation of the good cause claim.

TANF Transmittal 78