Page 122

ESS STAMP HANDBOOK DORMS AND INSTRUCTIONS

63-1230 (Cont) _ Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 DEA 842 (6/81)

14, BUMMARY OF FOOD STAMP OVER(BBUANCE

teowrinvarion! inciude ait other overissuance months not listed on the front i! the basis

of the claim is potential fraud ISSUANCE AGTUAL BASIS FOR ISSUANCE CORRECT BASIS FOR IBEUANCE IMUANCE VERIFICATION MONTI/ YEAR | HOUSE NOW GI2E JAUNTED INCOME|RONUE/ AULT WT] HOUSENOW FizE [ADIUSKD icoMElpouuWAuDMenrt oor TT REDEMPTION

‘DOGUMENTATION:

Total this page ‘4a Subtotal » i 14d Subtotal > ‘14b Subtotal gL 44s Sébtotal Total tirst page (irom ta)” ___ BES Sa Urom 1b) png Totai both pages ic Total » “met 14t Total » iz Total food stamp overissuance 140 Minus 141 » ‘5 Claim offsetting against lost beneflis not restored. Date oat A. Total food stamp overissuance {from 15 above} A. Minus lost benefits not restored, . Minus payment received, D. Amount of food stamp claim ta be collectad. Taig wmiLity WoaKeR SiauAT URE BRE TREAT OR TrenatRE Bae

‘DOCUMENTATION

CALIFORNIA-DSS-MANUAL-SS Issue 2239 Issued 8/14/81

(MANUAL LETTER NO. 81-39) _4\7,

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Page 122

Official source

ESS STAMP HANDBOOK DORMS AND INSTRUCTIONS

63-1230 (Cont) _ Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 DEA 842 (6/81)

14, BUMMARY OF FOOD STAMP OVER(BBUANCE

teowrinvarion! inciude ait other overissuance months not listed on the front i! the basis

of the claim is potential fraud ISSUANCE AGTUAL BASIS FOR ISSUANCE CORRECT BASIS FOR IBEUANCE IMUANCE VERIFICATION MONTI/ YEAR | HOUSE NOW GI2E JAUNTED INCOME|RONUE/ AULT WT] HOUSENOW FizE [ADIUSKD icoMElpouuWAuDMenrt oor TT REDEMPTION

‘DOGUMENTATION:

Total this page ‘4a Subtotal » i 14d Subtotal > ‘14b Subtotal gL 44s Sébtotal Total tirst page (irom ta)” ___ BES Sa Urom 1b) png Totai both pages ic Total » “met 14t Total » iz Total food stamp overissuance 140 Minus 141 » ‘5 Claim offsetting against lost beneflis not restored. Date oat A. Total food stamp overissuance {from 15 above} A. Minus lost benefits not restored, . Minus payment received, D. Amount of food stamp claim ta be collectad. Taig wmiLity WoaKeR SiauAT URE BRE TREAT OR TrenatRE Bae

‘DOCUMENTATION

CALIFORNIA-DSS-MANUAL-SS Issue 2239 Issued 8/14/81

(MANUAL LETTER NO. 81-39) _4\7,