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FOOD STAMP HANDBOOK —

Handbook _ FORMS AND INSTRUCTIONS

63-1230 (Cont.)

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 842 (6/81) (instructions Revised 3/84)

Form Instructions (For Eligibility Worker)

CLAIM DETERMINATION WORKSHEET

Purpose:

The DFA 842 is used to document claims against any household that has received more food stamp benefits than it is entitled to receive. This form has a twofold purpose: 1) completion of the form allows for internal documentation of individual claims, and 2) documentation of

individual claims assists counties in gathering information for the quarterly report DFA 209, Status of Claims Against Households.

The first page of the worksheet documents overissuances which occurred within the 12 months prior to the date of discovery. If the basis for the claim determination is inadvertent household error or administrative error, only the first page is completed. {f the basis for claim determin- ation is potential intentional program violation, the first page is completed, if applicable, and the second page is completed for overissuances which occurred more than 12 months prior to the date of discovery. Additional forms may be used as needed to document the amount of claim. However no amount of overissuarice which occurred in a month more than six years from the date the overissuance was discovered or prior to March 1, 1979 may be included.

For example, if the date of discovery is March 10, 1984, an inadvertent household error claim or administrative error claim covering the period March 1983 through March 1984 would be documented on the first page. A potential intentional program violation claim covering the period January 1, 1979 through March 1984, with a discovery date of March 10, 1984, would be documented as follows: March 1983 through March 1984 would be documented on the first page. February 1983 through March 1979 would be documented on the second page and additional pages as needed. Do not establish a claim for January and February 1979.

NOTE: Collection action on claims covering overissuances which occurred within the 12 months prior to the date of discovery may be initiated immediately regardless of the basis for the claim determination. Collection action on claims covering overissuances which occurred more than 12 months prior to the date of discovery may be initiated only after

an individual has been found guilty of committing an intentional program violation.

Preparation:

Complete the number of copies required for your internal system as soon as an overissuance is discovered and it is determined that a claim should be established.

1-7. Enter the following identifying information.

— Name of Head of Household

— Case Name (if different)