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§3-1230 (Cont) FORMS AND INSTRUCTIONS Handbook

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

DFA 842 (6/81) {Instructions Revised 3/84)

Check the type of issuance (direct mail, ATP or HIR}. Verify redemption of the ATP/HIR by noting

the date of redemption, serial number or other appropriate information in the redemption column.

lta. Total

Enter the total food stamp allotment actually received by the household for the overissuance months,

1b. Total

Enter the total food stamp allotment which should have been correctly received by the household for the overissuance months.

12. Total Food Stamp Overissuance

Subtract correct total allotment {11b) from allotment actually received (11a) and enter the remainder.

13. Claim Offsetting Lost Benefits Not Restored

Complete this section only if the household is due lost benefits which have not been restored or payment against the claim has been received, Enter the date that the claim is offset by lost benefits or payments. Space is provided to record a second offsetting should this occur while the claim is still open. Any additional offsetting may be shown in the documentation section. 134. Enter total food stamp overissuance from line 12.

13B. Enter any lost benefits not restored.

13C. Enter any payment received toward the claim.

13D. Subtract 13B and 13C from 13A and enter the remainder for the amount of the food stamp claim to be collected,

Signature Block Enter Eligibility Worker's name and date. Enter Eligibility Worker Supervisor's name and date of review.

The first page must be signed by the Eligibility Worker and Eligibility Worker Supervisor even if there is a continuation on the second page. :

Review By County Review Officer

Use this section to enter the action to be taken to collect the claim, and if it is referred for intentional program violation investigation. This section may also be used to record information such as the dates of repayment notices and the amounts collected; if the claim was suspended, and the date and reason; the date the claim is considered uncollectible and the date collection action is terminated.

CALIFORNIA-DSS-MANUAL-SS Rev. 1391e replaces Issue 2256 Eoctiva O/47R /QA4