Form FNS-380 Worksheet for Food Stamp Program Quality Control Reviews

FORM APPROVED OMB 0584-0074
U.S. DEPARTMENT OF AGRICULTURE - Food and Nutrition Service

WORKSHEET FOR FOOD STAMP PROGRAM QUALITY CONTROL REVIEWS
PRIVACY ACT NOTICE: This report is required under provisions of
7 CFR 275.14 (Food Stamp Program). This information is needed for
the review of State performance in determining recipient eligibility.
The information is used to determine State compliance and failure to
report may result in a finding of non-compliance.

OMB STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0584-0074. The
time required to complete this collection is estimated to average 8.9 hours per response,
including the time to review instructions, search existing data sources, gather the data needed,
and complete and review the information collection.

A. IDENTIFYING INFORMATION

B. PERSONS LIVING IN THE HOME
NAME

1. LOCAL AGENCY
2. CASE NAME
3. ADDRESS

BIRTH DATE

AGE

RELATIONSHIP
OR
SIGNIFICANCE

SOCIAL SECURITY
NUMBER

FS
RECIP.

1
2

4. PHONE NUMBER

3

5. DIRECTIONS TO LOCATE

4
5
6
7
8
9
10

6. CASE NUMBER
7. REVIEW NUMBER

C. SIGNIFICANT PERSONS NOT LIVING IN THE HOME

8. REVIEW DATE
9. RESERVED

NAME

10. MOST RECENT ACTION
a. Date
b. Type
11. CERTIFICATION PERIOD

RELATIONSHIP
OR
SIGNIFICANCE

From
To

12. PART. DURING SAMPLE MONTH

YES

NO

13. REC' D EXPEDITED SERVICE

YES

NO

14. CATEGORICALLY ELIGIBLE HH

YES

NO

15. REVIEWER
16. DATE ASSIGNED

SOC. SECURITY
NUMBER

ADDRESS

FINANCIAL
SUPPORT

11
12
13
14
15
D. REVIEW FINDINGS
ALLOTMENT

17. DATE OF CASE READING

AMOUNT CORRECT

UNDERISSUANCE

18. DATE OF INTERVIEW
19. DATE COMPLETED

OVERISSUANCE

INELIGIBLE

20. SUPERVISOR

PHONE
NUMBER

AMOUNT IN ERROR

21. DATE CLEARED
FORM FNS-380 (9-03) Previous editions are obsolete.

Electronic Form Version Designed in JetForm 5.01 Version

Page 1

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
110 AGE

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)

RESULTS

(3)

(4)

(2)
BASIC PROGRAM REQUIREMENTS (100)

1 = No error
2 = Agency error
3 = Client error

111 STUDENT STATUS

1 = No error
2 = Agency error
3 = Client error

130 CITIZENSHIP AND NON-CITIZEN
STATUS

1 = No error
2 = Agency error
3 = Client error

140 RESIDENCY

1 = No error
2 = Agency error
3 = Client error

Page 2

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
150 HOUSEHOLD COMPOSITION

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)

RESULTS

(3)

(4)
1 = No error
2 = Agency error
3 = Client error

151 RECIPIENT DISQUALIFICATION

1 = No error
2 = Agency error
3 = Client error

WORK REQUIREMENTS
160 EMPLOYMENT & TRAINING
PROGRAMS

1 = No error
2 = Agency error
3 = Client error

161 TIME LIMITED PARTICIPATION

1 = No error
2 = Agency error
3 = Client error

162 WORK REGISTRATION

1 = No error
2 = Agency error
3 = Client error

163 VOLUNTARY QUIT/REDUCING
WORK EFFORT

1 = No error
2 = Agency error
3 = Client error
Page 3

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION

(2)

(Facts obtained, verification and
substantiation, nature of errors)
(3)

164 WORKFARE AND COMPARABLE
WORKFARE

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

165 EMPLOYMENT STATUS/JOB
AVAILABILITY

1 = No error
2 = Agency error
3 = Client error

166 ACCEPTANCE OF EMPLOYMENT

1 = No error
2 = Agency error
3 = Client error

170 SOCIAL SECURITY NUMBER

1 = No error
2 = Agency error
3 = Client error

LIQUID RESOURCES
211 BANK ACCOUNTS OR CASH ON
HAND

RESOURCES (200)
1 = No error
2 = Agency error
3 = Client error
Page 4

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
212 NONRECURRING LUMP-SUM
PAYMENTS

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

213 OTHER LIQUID ASSETS

1 = No error
2 = Agency error
3 = Client error

NON-LIQUID RESOURCES

1 = No error

221 REAL PROPERTY
2 = Agency error
3 = Client error

222 VEHICLE

1 = No error
2 = Agency error
3 = Client error

Page 5

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
224 OTHER NON-LIQUID RESOURCES

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

225 COMBINED RESOURCES

1 = No error
2 = Agency error
3 = Client error

Page 6

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
EARNED INCOME

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)

(2)

(3)
INCOME (300)

RESULTS

(4)
1 = No error

311 WAGES AND SALARIES
2 = Agency error
3 = Client error

312 SELF-EMPLOYMENT

1 = No error
2 = Agency error
3 = Client error

Page 7

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
314 OTHER EARNED INCOME

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

EARNED INCOME DEDUCTIONS

1 = No error

321 EARNED INCOME DEDUCTIONS
2 = Agency error
3 = Client error

323 DEPENDENT CARE DEDUCTIONS

1 = No error
2 = Agency error
3 = Client error

Page 8

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
UNEARNED INCOME

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)

RESULTS

(3)

(4)
1 = No error

331 RSDI BENEFITS
2 = Agency error
3 = Client error

332 VETERANS BENEFITS

1 = No error
2 = Agency error
3 = Client error

333 SSI AND/OR STATE SSI
SUPPLEMENT

1 = No error
2 = Agency error
3 = Client error

334 UNEMPLOYMENT
COMPENSATION

1 = No error
2 = Agency error
3 = Client error

Page 9

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
335 WORKER' S COMPENSATION

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

336 OTHER GOVERNMENT BENEFITS

1 = No error
2 = Agency error
3 = Client error

342 CONTRIBUTIONS

1 = No error
2 = Agency error
3 = Client error

343 DEEMED INCOME

1 = No error
2 = Agency error
3 = Client error

Page 10

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
344 TANF, PA or GA

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

345 EDUCATIONAL GRANTS/
SCHOLARSHIPS/LOANS

1 = No error
2 = Agency error
3 = Client error

346 OTHER UNEARNED INCOME

1 = No error
2 = Agency error
3 = Client error

350 CHILD SUPPORT PAYMENTS
RECEIVED FROM ABSENT
PARENT

1 = No error
2 = Agency error
3 = Client error

Page 11

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
OTHER DEDUCTIONS

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error

361 STANDARD DEDUCTION
2 = Agency error
3 = Client error

363 SHELTER DEDUCTION

1 = No error
2 = Agency error
3 = Client error

364 STANDARD UTILITY ALLOWANCE

1 = No error
2 = Agency error
3 = Client error

Page 12

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
365 MEDICAL DEDUCTION

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

366 CHILD SUPPORT PAYMENT
DEDUCTION

1 = No error
2 = Agency error
3 = Client error

371 COMBINED GROSS INCOME

1 = No error
2 = Agency error
3 = Client error

372 COMBINED NET INCOME

1 = No error
2 = Agency error
3 = Client error

Page 13

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION
ELEMENTS OF ELIGIBILITY AND
BASIS OF ISSUANCE

(1)
520 ARITHMETIC COMPUTATION

QC ANALYSIS OF CASE RECORD
(Pertinent facts, sources of
verification, reliability, gaps or
deficiencies)
(2)

REVIEW NO.

FINDINGS OF FIELD INVESTIGATION
(Facts obtained, verification and
substantiation, nature of errors)
(3)

RESULTS

(4)
1 = No error
2 = Agency error
3 = Client error

530 TRANSITIONAL BENEFITS

1 = No error
2 = Agency error
3 = Client error

560 REPORTING SYSTEM

1 = No error
2 = Agency error
3 = Client error

810 FOOD STAMP SIMPLIFICATION PROJECT

1 = No error
2 = Agency error
3 = Client error

820 DEMONSTRATION PROJECTS

1 = No error
2 = Agency error
3 = Client error

Page 14

FOOD STAMP PROGRAM QUALITY CONTROL
COMPUTATION SHEET
ELIGIBILITY
WORKER
(1)

FINAL SAQC
DETERMINATION
(2)

(3)

(4)

(5)

Wages, salaries, Federal w orkstudy minus allow able
expenses, or other income from employment. (Do not
count excluded income)

Member

:

Source

:
:
:
1. Add Line K from Self-Employment
addendum sheet (if applicable) and
all earned income listed above.
Educational grants, scholarships, or loans
(except Federal w orkstudy)
2. Enter monthly income received from
educational grants, etc..
3. Enter monthly tuition and mandatory
fees and other allow able expenses.
4. Subtract 3 from 2.
5. Add lines 1 and 4.
Unearned income (Do not count excluded income)

:
:
:
6. Total unearned income.
Gross monthly income
7. Add lines 5 and 6.
8. Enter net loss from line K,
if applicable.
9. Subtract line 8 from 7. (Result
is gross monthly income.)
10. Enter appropriate gross
income eligibility limit.
Go to line 11 only if:
- line 9 is less than or equal to line 10; or
- household contains an elderly/disabled member; or
- household is categorically eligible for food stamps.
DEDUCTIONS: (Other than shelter)
11. Multiply line 1 by 20% and enter
result here.
12. Subtract 11 from 9.
13. Enter standard deduction.
14. Subtract line 13 from 12.
15. Enter medical costs over limit for
household w ith elderly/disabled member.
16. Subtract line 15 from 14.
17. Enter dependent care costs
(not to exceed authorized limit).
18. Subtract line 17 from 16.
19. Enter child support.
20. Subtract line 19 from 18.
Page 15

FOOD STAMP PROGRAM QUALITY CONTROL
COMPUTATION SHEET
ELIGIBILITY
WORKER
(1)

FINAL SAQC
DETERMINATION
(2)

(3)

(4)

(5)

21. Enter homeless shelter deduction, if
applicable.
22. Subtract 21 from 20.
23. If household had shelter costs, and did
not receive a homeless shelter deduction
divide line 22 by 2.
SHELTER COSTS: (Use either the utility standard or
the actual cost of each utility bill.)
Rent or mortgage
Taxes and insurance
Total utility standard
Telephone (Basic rate)
Electric
Gas
Oil
Water and Sew erage
Garbage and trash
Installation of utilities
Other
24. Total shelter costs
25. Enter amount from line 23.
26. Subtract line 25 from 24 (Result
equals excess shelter costs).
27. If no elderly/disabled member, enter
the maximum limit for the shelter
deduction.
NET MONTHLY INCOME
28. Enter amount from line 20 (income
after all deductions except shelter)
29. If elderly/disabled member, enter line
26. For all other households, enter
amount from line 26 or 27, w hichever
is less.
30. Subtract line 29 from 28. (Result
equals net monthly income.)
31. Enter appropriate net income
eligibility limit.
Go to line 32 only if:
-- Line 30 is less than or equal to line 31; OR
-- all members of the HH are categorically eligible.
ALLOTMENT LEVEL
32. Enter Thrifty Food Plan for household
size.
33 Multiply line 30 by 30% and enter
result here.
34. Subtract line 33 from 32; (prorating or
applying minimum allotment if
required.)
Page 16

FOOD STAMP PROGRAM QUALITY CONTROL
COMPUTATION SHEET
SELF-EMPLOYMENT ADDENDUM
FOR HOUSEHOLDS WITH SELF-EMPLOYMENT I
INCOME: START AT STEP A AND WORK THROUGH
STEP K. DO THE STEPS IN ORDER. IF A NEGATIVE
NUMBER RESULTS AFTER SUBTRACTING TWO
NUMBERS, INSERT ZERO, EXCEPT LINES O, J, AND
K.

ELIGIBILITY
WORKER
(1)

FINAL SAQC
DETERMINATION
(2)

(3)

(4)

(5)

FARM SELF-EMPLOYMENT INCOME
HOUSEHOLD MEMBERS

:

SOURCE

:
:
A. Total monthly gross farm
self-employment income
B. Enter monthly farm business costs
SUBTRACT LINE B FROM LINE A, AND:
C. If gross income exceeds costs
enter figure here as not farm gain.
D. If business costs exceed gross
income, enter figure here as net
farm gain.

SELF-EMPLOYMENT INCOME OTHER
THAN FARMING (Include room and
board payments)
:
:
:
E. Total monthly gross self-employment
income other than farming.
F. Enter monthly farm self-employment
income from line C (If Applicable)
G. Add lines E and F. (Result is total
self-employment income.)
H. Enter monthly business cost
other than farming.
I. Subtract line H from G. (Result is
net monthly self-employment income
before taxes; (If Less Than O, Enter 0.)
J. Enter net farm loss from line D
(If none, enter 0)
K. Subtract line J from I. Enter as a
positive number, a negative number
or 0.

If line K show s a net gain, add to w ages and salaries on line 1 and enter 0 on line 8 of the Computation Sheet.
If Line K show s a net loss, enter amount on line 8 of the Computation Sheet and make no entry for self-employed income on line 1.

Page 17