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tlandbook pmennmnnnLORMS AND INSTRUCTIONS 83-1230 (Cont. 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 DFA 842 (6/81)

(Instructions Revised 3/84)

14. Summary of Food Stamp Overissuance

Complete this section only for potential intentional program violation claims where over- issuances occurred more than 12 months prior to the date of discovery.

Issuance Month/Year

Enter the month and year of all overissuances which occurred more than 12 months prior to the date of discovery. Use an additional sheet, if necessary.

Actual Basis for Issuance ~~ HH Size

Enter the household size used in the original benefit computation. — Adjusted Income

Enter the net adjusted income from the original benefit computation. — Bonus/Allotment

Enter the allotment actually received by the household for each overissuance month. Correct Basis for Issuance — HH Size

Enter the correct household size for each overissuance month. — Adjusted Income

Enter the correct net adjusted income for each overissuance month. — Bonus/Allotment

Enter the correct allotment the household should have received.

issuance Verification Use of this section to verify issuance of the benefits covered by the claim is a county option. If this

section is not used for this purpose, verification of issuance must be documented in some other

manner. For verification of ATP usage, the DFA 332.1, Verification of Food Stamp ATP Usage, may be used.

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.