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63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230 DFA 285-D (12/83)

Enter the issuance month for each calculation and complete Lines L1 through L4. Enter the amount on Line L4 on Line B4 of the appropriate budget.

Part 6 — Reported Changes

For changes reported outside of the monthly report (CA 7) or the household change report (DFA 377.5), enter the type of change, date the change occurred, date the change was reported, and the EW initials.

Rev. 1372 replaces issues 2196 and 2197

(MANUAL LETTER NO. 84-13} fy(p 2D