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LIHEAP - ERRONEOUS PAYMENT REVIEW/REPORT ADMINISTRATIVE DATA TYPE OF ERRONEOUS PAYMENT: SSN 1ST REPORT? YES NO CLIENT ERROR
AGENCY
AGENCY ERROR
CLIENT NAME PHONE SUSPECTED FRAUD
OVERPAYMENT
Amount $___________ CLIENT ADDRESS COUNTY INELIGIBLE PAYMENT Amount $___________
SUMMARY OF INFORMATION
Give a brief description of the erroneous payment to include: 1) Circumstances of the erroneous payment; 2) Worker statement; 3) Client statement; and 4) How you arrived at the dollar value. (Attach additional sheets if needed.)
DATE INVESTIGATOR SIGNATURE
DIRECTOR SIGNATURE STATE OFFICE USE ONLY COMMENTS/RECOMMENDATIONS
DATE SUPERVISOR
FILE LIHEAP-119 Reviewed 2024