Page 121

Handbook _

FOOD STAMP HANDBOOK FORMS AND INSTRUCTIONS

63-1230 (Cont)

63-1230 STATE FORMS

& INSTRUCTIONS (Continued)

63-1230 DFA 842 (6/81)

STATE OF GALIFOMIA = WEALTH AND WELFARE 4BtHEY DEPanTWeNT OF S0ctAL SERVICES CLAIM DETERMINATION WORKSHEET more RE REIT ETPPEHRTT pera €, AGGRESS SL FECEPRORE G. WRTSATE FRET ee oe TaCOVERY 1S. SARIS FOR Claw GE TERMINATION: ee a ‘gers TB. TLRPTAWATI ON GF OVERIASUANCE TIF APPLICABLE, IMCLUDE DATE CHANGE OCCURRED AND DATE REPORTEDT Sinaaany Gr FOES BTA OVEATRRUANCE Taciude on this page only those overissuance months which ara within 12 montha prior to date of discovery. iuaAKCE ACTUAL BARS FOR ISSUANCE CORRECT BASIS FOR ISSUANCE IBSUANCE VERIFICATION wonrivean (rousewoun size [anuareo incowd aLiorment — [woustnoun sire lapse reo weowd aucorwent | oa [DR REDEMPTION Continue on reverse for I amar | DCUMER TATION oni t tal Inu on reverse tt Total» tb Tota 12 Totat food stamp overissuance: (subtotal it continued on reverse) {1a Minus 11b » OTE: wre 15" Chaim offsetting lost benefit not restored. A. Total food stamp overissuance (trom 12 above). B, Minus lost benefits not restored. C. Minus payment received. D._Amounl of tood stamp claim to be collected. TLIGIBILITY WORKER SIGMATURE Gate AUPERVERON S1GRA TURE DATE REVIEW BY COUNTY REVIEW OFFICER TeTGN TAMER? COT HETEW BIPTEEN SORTA sit BPA B42 16/81) Requited Form Substtiuies Permitiad PUD URC eo

CALIFORNIA-DSS-MANUAL-SS

Issue 2238

issued 8/14/84

(MANUAL LETTER NO. 81-39)

Tid ‘