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

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OMB 0584-0074 APPENDIX A

FORM APPROVED OMB 0584-0074
Expiration Date XX/XXXX

U.S. DEPARTMENT OF AGRICULTURE - Food and Nutrition Service

WORKSHEET FOR QUALITY CONTROL REVIEWS
PRIVACY ACT NOTICE: This report is required under provisions of
7 CFR 275.14 (SNAP). 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

1. LOCAL AGENCY
2. CASE NAME
3. ADDRESS

NAME

BIRTH DATE

RELATIONSHIP
OR
SIGNIFICANCE

SOCIAL
SECURITY
NUMBER

SNAP
RECIPIENT

1
2
3
4
5
6
7
8
9
10

4. PHONE NUMBER
5. DIRECTIONS TO LOCATE

6. CASE NUMBER

C. SIGNIFICANT PERSONS NOT LIVING IN THE HOME

7. REVIEW NUMBER
8. REVIEW DATE
9. RESERVED
10. MOST RECENT ACTION
a. Date
b. Type
11. CERTIFICATION PERIOD

AGE

RELATIONSHIP
OR
SIGNIFICANCE

NAME

From:
To:

12. PART. DURING SAMPLE MONTH
13. REC'D EXPEDITED SERVICE
14. CATEGORICALLY ELIGIBLE HH
15. REVIEWER
16. DATE ASSIGNED
17. DATE OF CASE READING
18. DATE OF INTERVIEW
19. DATE COMPLETED
20. SUPERVISOR
21. DATE CLEARED
FNS-380 (12/08) Previous Editions Obsolete
Electronic Form Version Designed in Adobe 8.1 Version

YES

NO

YES

NO

YES

NO

11
12
13
14
15

SOCIAL
SECURITY
NUMBER

ADDRESS

PHONE
NUMBER

FINANCIAL
SUPPORT

D. REVIEW FINDINGS
ALLOTMENT

AMOUNT CORRECT

UNDERISSUANCE

OVERISSUANCE

INELIGIBLE

AMOUNT IN ERROR

SBU

Page 1

ELEMENTS OF ELIGIBILITY AND PAYMENT DETERMINATION

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

110 AGE

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 NONCITIZEN 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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

150 HOUSEHOLD COMPOSITION

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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

164 WORKFARE AND COMPARABLE
WORKFARE

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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

212 NONRECURRING LUMP-SUM
PAYMENTS

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
221 REAL PROPERTY

1 = No error
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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

224 OTHER NON-LIQUID RESOURCES

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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

EARNED INCOME
311 WAGES AND SALARIES

INCOME (300)

1 = No error
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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

314 OTHER EARNED INCOME

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

EARNED INCOME DEDUCTIONS
321 EARNED INCOME DEDUCTIONS

1 = No error
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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

UNEARNED INCOME
331 RSDI BENEFITS

1 = No error
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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

335 WORKER'S COMPENSATION

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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

344 TANF, PA or GA

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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

OTHER DEDUCTIONS
361 STANDARD DEDUCTION

1 = No error
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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

365 MEDICAL DEDUCTION

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

REVIEW NO.

ELEMENTS OF ELIGIBILITY
AND BASIS OF ISSUANCE

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

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

RESULTS

(1)

(2)

(3)

(4)

520 ARITHMETIC COMPUTATION

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 SNAP 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

QUALITY CONTROL
COMPUTATION SHEET
ELIGIBILITY
WORKER

FINAL SAQC
DETERMINATION

(1)

(2)

(3)

(4)

(5)

Wages, salaries, Federal workstudy minus allowable
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 workstudy)
2. Enter monthly income received from
educational grants, etc..
3. Enter monthly tuition and mandatory
fees and other allowable 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 SNAP Benefits.
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 with 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

QUALITY CONTROL
COMPUTATION SHEET
ELIGIBILITY
WORKER

FINAL SAQC
DETERMINATION

(1)

(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 Sewage
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, whichever
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

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

FINAL SAQC
DETERMINATION

(1)

(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 shows a net gain, add to wages and salaries on line 1 and enter 0 on line 8 of the Computation Sheet.
If Line K shows 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