Form FNS-245 Quality Control - Food Stamp Negative Case Action Review

FORM APPROVED OMB NO. 0 584 -00 34
U.S. DEPARTMENT OF AGRICULTURE - FOOD A ND NUTRITION SERV ICE

QUALITY CONTROL - FOOD STAMP NEGATIVE CASE ACTION
REVIEW SCHEDULE
I. CASE MANAGEMENT INFORMATION (Not to be Transmit t ed)
1 . CA SE NA ME (Last, First, MI)

2 . TELEPHONE NUMBER

3 . M AILING A DDRESS

4 . A CTUA L A DDRESS/DIRECTIONS TO LOCA TE

5 . DA TE A SSIGNED
MO

6 . DA TE COMPLETED/DISPOSED OF
DAY

YEAR

MO

DAY

7 . DA TE CLEA RED

YEAR

MO

Revi ew er

DAY

YEAR

Sup ervi so r

II. IDENTIFYING INFORMATION
A . REVIEW NUM BER

B. CA SE NUMBER

E. STRA TUM

C. STA TE A ND LO CA L A GENCY
CODES

F. DECISION DA TE
MO

H. A CTION TYPE

G. EFFECTIVE DATE

DAY

YEAR

MO

DAY

D. SA MPLE MONTH A ND YEA R

I. CA SE CLA SSIFICA TION

YEAR

III. ANALYSIS OF REVIEW ACTIVITY
J. NOTICE REQ UIREM ENTS

K. RECORDED REA SON FOR A CTION

L. V A LIDITY OF RECORDED REA SON

M. RESULT OF EXPA NDED REV IEW

N. DISPOSITION OF REV IEW
(b )

(a) V alid ity

Reason fo r A ct ion
(If d iff eren t f rom item L;
o ther w ise, en ter " 0 0 ")

IV. DESCRIPTION OF VARIANCES
O. ELEM ENT CO DE

1.

P. NA TURE CODE

2.

3.

1.

2.

3.

RESERV ED (Federal Use)

OPTIONAL (State Systems Only)

V . EX PLANATION OF REV IEW FINDINGS (Not to be transmitted - Continue on reverse side)

FORM FNS-245 (1-04) Previous edit ions obsolete

El ectro ni c For m V ersion Desi gn ed in Jet For m 5 .0 1 Ver si on

EX PLA NA TION OF REVIEW FINDINGS CONTINUED:

PRIV ACY ACT STATEMENT

OMB PAPERWORK COLLECTION STATEMENT

This report is required under prov isions of 7 CFR
27 5.1 4 (The Food St amp Program). This inf ormat ion is needed f or the review of St at e perf ormance
in det ermining t he eligibilit y of applicant s and
recipient s. The inf ormat ion is used t o det ermine
State compliance, and f ailure t o report may result
in a f inding of non-compliance.

A ccording to t he Paperw ork Reduct ion A ct of 1 995,
no persons are required to respond t o a c ollect ion of
inf ormat ion unless it displays a v alid OMB cont rol
number. The valid OMB cont rol number f or t his
inf ormat ion collec tion is 05 84-0034 . The t ime
required t o complet e t his inf ormat ion collec tion is
est imated t o average 3. 023 6 hours per response,
including t he t ime f or rev iew ing inst ruct ions, searching
ex isting dat a sources, gat hering and maint aining the
dat a needed, and c omplet ing and rev iew ing the collec t ion of inf ormat ion.