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

NOTE:

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

— Case Number

-- Address

~- Telephone Number

—~ Birthdate

— Social Security Number

lf a claim applies to a sponsored alien household, enter the name of both the head of house-

hold and the sponsor in item 1. Document if collection action is initiated against the sponsor, the alien, or both.

Date of Discovery

Enter the date the overissuance became known to the CWD.

9. Basis for Claim Determination Check the appropriate box for the cause of the overissuance. For purposes of completing this section, the types of claims. are as follows: — Inadvertent Household Error Claim (Check household error box on form.) A claim in which an overissuance was caused by a misunderstanding or unintended error on the part of the household (or sponsor of an alien household), — Administrative Error Claim {Check administrative/procedural error box on form.) A claim in which the overissuance was caused by the CWD. -~ Potential Intentional Program Violation Claim (Check potential fraud box on form.) A claim in which a household member is suspected of intentionally violating program rules or regulations to receive more food stamps. A claim is handled as an intentional program violation claim only after an administrative disqualification hearing official or a court of appropriate jurisdiction has determined that a household member (or the sponsor of an alien household} has committed an intentional program violation. 10. Explanation of Overissuance Explain how and why the overissuance occurred. if the overissuance resulted from a change in circumstances, indicate the date the change occurred and the date the household reported the change to the CWD. CALIFORNIA-DSS-MANUAL-SS Rev. 1391¢ replaces Issue 2254 Effective 2/15/84