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83-1230 (Cont.). FORMS AND INSTRUCTIONS Handbook

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

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

14a, Subtotal This Page

Enter the total food stamp allotment received by the household from this page.

14b. Subtotal First Page

Enter the total allotment received by the household from item 11a of the first page.

14¢. Total Both Pages Add 14a and 14b and enter total, 14d. Subtotal This Page

Enter total food stamp allotment which should have correctly been received by the household from this page.

14e. Subtotal First Page

Enter total allotment which should have correctly been received by the household from item 11b of the first page.

14f. Total Both Pages Add 14d and 146 and enter totai.

15. Total Food Stamp Overissuance

Subtract correct tota! food stamps (14f) from food stamps actually received (14c) and enter remainder,

16. Claim Offsetting Lost Benefits Not Restored

Complete this section only if the household is due lost benefits not restored or payment against the claim has been received and this offsetting was not done on the first page. Enter the date that the claim is offset by the 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,

16A. Enter total food stamp overissuance from line 15. 168. Enter any lost benefits not restored.

16C. Enter any payment received toward the claim,

16D. Subtract 16B and 18C from 16A and enter the remainder for the amount of food stamp intentional program violation claim to be collected,

Signature Block Enter Eligibility Worker’s name and date.

Enter Eligibility Worker Supervisor’s name and date of review.

Documentation

Use this section if additional Space is required to document action taken on the claim or to document other information required by the county.

CALIFORNIA-DSS-MANUAL-SS Rev, 1391g replaces Issue 2258 Effective 2/15/84