Appendix A: System-Generated Notice of Ineligibility at Application

Reason #070, OPTION H

You and your family are ineligible for Cash Assistance because you did not complete the Agreement of Mutual Responsibility (AMR) dated ________. Each applicant who is required to complete and sign the application must complete and sign an appropriate AMR. You and your family are ineligible for Cash Assistance until you sign the AMR indicating that you agree to comply with the obligations and responsibilities listed on this AMR.

Legal Authority: 62 P.S. 401and 405.3(a)

Reissued:  January 31, 2012 replacing December 16, 2008; reviewed December 11, 2017