Form 380-1 Quality Control Review Schedule

Quality Control Review Schedule

4 & 5. FNS-380-1 with instructions- updated April 2012

Quality Control Review Schedule

OMB: 0584-0299

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U.S. Department of Agriculture - Food and Nutrition Service

OMB APPROVED NO. 0584-0299
Expiration Date: XX/XX/XXXX

QUALITY CONTROL REVIEW SCHEDULE

PRIVACY ACT/PAPERWORK REDUCTION ACT. 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 0584-0299. The time required
to complete this collection is estimated to average 1.056 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. This report is required under provisions of 7 CFR 275.14. 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.

Section 1 - Review Summary
1. QC Review Number

7. Disposition

2. Case Number

8. Findings

3. State

9.SNAP Allotment Under Review

4. Local Agency

5. Sample Month and Year

10. Error Amount

6. Stratum

11. Case Classification

Section 2 - Detailed Error Findings
12. Element

13. Nature

14. Cause

15. Error Finding 16. Error Amount

17. Discovery

18. Verified 19. Occurrence
a. Date

b. Time Period

8
FORM FNS-380-1 (02/12) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 9.1 Version

Section 3 - Household Characteristics
20. Most Recent Cert. Action
Month, Day, Year

25. Number of
Household Members

21. Type of Action

26. Receipt of
Expedited Service

22. Length of Cert. Period
#of months

27. Authorized Representative
Used at Application

23. Allotment Adjustment

28. Categorical Eligibility

24. Amount of
Allotment Adjustment

29. Reporting Requirement

Resources:
30. Liquid

31. Property
(excluding home)

32a. Vehicle

32b. Status
2nd Vehicle

33. Countable
Vehicle Assets

34. Other Non-liquid

Income:
35. Gross

36. Net

Deductions:
37. Earned Income

Additional
Information on
Shelter Costs:

38. Medical

39. Dependent Care

43. Rent/Mortgage

44. Use of SUA
a. Usage
b. Proration

40. Child Support

41. Shelter

42. Homeless

45. Utilities (SUA or Actual)

Section 4 - Information on Each Household Member
46. Person
Number

47. SNAP
48. Relation
Participation
to Head
of HH

49. Age

50. Sex

51. Race

52. Citizen
Status

53. Edu.
Level

54. Employment
Status
Hours

55. SNAP
Work Reg.

56. SNAP
E&T

57. ABAWD 58. Dependent
Status
Care Cost

You may record information on up to 16 individuals using additional pages.

Section 5 - Income Identified by Household Member
59. Person
Number

Source 1
60. Income Type

Source 2
62. Income Type

61. Amount

63. Amount

Source 3
64. Income Type

65. Amount

Source 4
66. Income Type

67. Amount

You may record income on up to 10 individuals by using additional pages.

Section 6 - Reserved Coding
68.

69.

70.

71.

72.

73.

74.

75.

76.

Section 7 - Optional For State Use
1.
2.
3.
4.

INSTRUCTIONS FOR COMPLETING FORM FNS 380-1,
QUALITY CONTROL REVIEW SCHEDULE
GENERAL INFORMATION
The Quality Control Review Schedule (QCRS) is the data entry form to record the results of Food
Stamp Quality Control reviews.
The schedule consists of seven sections:
1 - Review Summary
2 - Detailed Error Findings
3 - Household Characteristics
4 - Information on Each Household Member
5 - Income Identified by Household Member
6 - Reserved Coding
7 - Optional - For State Systems Only
All entries in the QCRS are dollar amounts, dates, or numeric codes.

Dates - Use six or eight-digit numbers as the entry requires. For example,
October 3, 2003 would be coded:
1 0 0 3 2 0 0 3
The October sample month would be coded:

1 0 2 0 0 3

Dollar Amounts - Round all dollar amounts to the nearest dollar; leading zeros are not required.
For example, $165.00 is entered:
0 1 6 5
Not Applicable - If an item does not apply to the case reviewed, leave the applicable
boxes blank:

Unknown - If an item is known to exist but the specific amount is not known, fill in all boxes for that
item with 9's:
9 9 9 9
If no information is available or if the item does not apply to the household, leave the boxes blank.
Do not enter zeros to indicate no information.

Stratum - States with stratified samples should submit to the FNS regional office a listing of the
numeric codes utilized to identify stratum. Stratum codes are assigned by the State agency when
the sample is stratified. If stratum codes are not used, leave blank or enter other identifying
information at State option.
Local Agency Code - This code is used to group data by county or county equivalent or smaller
areas. The system requires a three-digit code.
The State may use Federal Information Processing Standards (FIPS) codes or use an alternative
method to designate local agency. Once a State has selected a method, submit to the FNS regional
office a listing of the local agencies and corresponding codes.
FIPS Codes - The National Institute of Standards and Technology has developed codes for
classification of counties and county equivalents. These codes were devised by listing counties
alphabetically and assigning sequentially odd integers; e.g., 001, 003, 005.

QUALITY CONTROL REVIEW SCHEDULE

SECTION 1 - REVIEW SUMMARY
This section records the final determination of the QC review. It is used to compute
the States payment error rate.
1. QC Review Number - Enter the number assigned to the Quality Control review.
2. Case Number - Enter the number assigned by the local agency to the household that was
certified and has been reviewed.
3. State code - Enter the two digit State code from the following list of codes of National Institute of
Standards and Technology.

State Codes - National Institute of Standards and Technology
State

Code

State

Code

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri

01
02
04
05
06
08
09
10
11
12
13
66
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming

30
31
32
33
34
35
36
37
38
39
40
41
42
44
45
46
47
48
49
50
78
51
53
54
55
56

Local Agency Code - Enter the three-digit code designating the local agency for this case.

Sample Month and Year - Enter the month and year for which the case eligibility and benefit
level were reviewed.

Stratum - Enter the two-digit stratum codes if sampling is stratified. If not stratified enter a
State optional code or leave blank.

Disposition - Enter one of the following codes:
1 - Complete
2 - Not subject to review
3 - Incomplete
4 - Case deselected
If codes 2, 3, or 4 are used, no further entries are required on the remainder of the review
schedule except item 68, reserved code for Timeliness of Application Processing (Expedited
and 30 Day Requirement).

Review Findings - Enter one of the following codes:
1 - Amount correct
2 - Overissuance
3 - Underissuance
4 - Ineligible
Enter actual finding regardless of whether it is below the error threshold. Do not complete
sections 4 and 5 if code 4, ineligible, is used.

FS Allotment Under Review - Enter the authorized amount of food stamps subject to review
for the sample month.

10.

Error Amount - Enter the dollar amount of any identified error. The dollar amount of the error is
the difference between the benefits the State authorized and the benefits the State should have
authorized regardless of the error threshold. Use the lower error amount from comparison one
or comparison two.

·
·

For overissuance or underissuance errors, enter the actual error amount whether or not
it exceeds $50.00.
For ineligible errors, enter the full amount of the error.

11.

Case Classification - Enter one of the following codes:
1 - Included in error rate calculation.
2 - Excluded from error rate calculation - processed by SSA worker.
3 - Excluded from error rate calculation, as designated by FNS (e.g. demo project, simplified
SNAP).

SECTION 2 - DETAILED ERROR FINDINGS
This section provides for the detailed coding of each variance identified during the QC review. If
additional lines are needed to code error findings, attach an additional page. Since the information
recorded in this section is the basis for corrective actions, the accuracy of the information is
important. If more than one variance is identified, the variance that the agency believes is most
significant in leading to the error should be listed first.
12.

Element - Enter the appropriate element number of the review for each variance identified.

13.

Nature codes - Enter the appropriate code for the nature of each variance.
The following provides the element and nature codes to be used in items 12 and 13.
These nature codes may be used in any element:
Nature code (97) - Not required to be reported or acted upon based on timeframes and
reporting requirements for allotment differences below the $50 threshold.
Nature code (98) - Transcription or computation errors.
Nature code (99) - Other. Use this nature code in the following situations:
a) If no specific nature code is listed under an element,
b) If the nature of the error is clearly understood by looking at the agency/client
code recorded for the error, or
c) If none of the listed nature codes under an element apply to the error being
recorded.

BASIC PROGRAM REQUIREMENTS - (100)
Ø

Element 111 - Student Status
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Element 130 - Citizenship and Non-Citizen Status
Nature codes:
Citizens
6 - Eligible person(s) excluded
7 - Ineligible person(s) included
124 - Variance resulting from use of automatic Federal information exchange system
Non-Citizens
200 - Eligible non-citizen excluded
201 - Ineligible non-citizen included
124 - Variance resulting from use of automatic Federal information exchange system

Element 140 - Residency
Nature codes:
99 - Other

Element 150 - Household Composition
Note: Variances should be coded under this element if a person or persons are unreported or
incorrectly reported, unprocessed or incorrectly processed, and these persons also have income,
resources or deductible expenses, which must be considered in the error determination.

For example: the discovery of an unreported 62 year old with earned income, a bank account, and
medical expenses would be recorded under Element 150 (Household Composition), not Elements
211 (Bank Accounts or Cash on Hand), 311 (Wages and Salaries), and 365 (Medical Deduction).
Variances should not be coded under this Element for persons with characteristics that are
specifically addressed under other 100 Series Elements (Student Status through Social Security
Number). For example: the discovery of an eligible non-citizen in the household who was
improperly excluded would be coded under Element 130 (Citizenship and Non-Citizen Status), not
under Element 150 (Household Composition).
Nature codes:
7 - Ineligible person(s) included
12 - Eligible person(s) with no income, resources, or deductible expenses excluded
13 - Eligible person(s) with income excluded
14 - Eligible person(s) with resources excluded
15 - Eligible person(s) with deductible expenses excluded
16 - Newborn infant improperly excluded

Element 151 - Recipient Disqualification
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Element 160 - Employment & Training Programs
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Element 161 - Time-limited Participation
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Ø Element 162 - Work Registration Requirements
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Ø Element 163 - Voluntary Quit/Reduced Work Effort
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Ø Element 164 - Workfare and Comparable Workfare
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Ø Element 165 - Employment Status/Job Availability
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Ø Element 166 - Acceptance of Employment
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

Ø Element 170 - Social Security Number
Nature codes:
6 - Eligible person(s) excluded
7 - Ineligible person(s) included

RESOURCES - (200)
Liquid Resources
Ø Element 211 - Bank Accounts or Cash on Hand
Nature codes:
24 - Resource should have been excluded
30 - Resource should have been included

Ø Element 212 - Nonrecurring Lump-sum Payment
Nature codes:
24 - Resource should have been excluded
30 - Resource should have been included

Ø Element 213 - Other Liquid Assets
Nature codes:
24 - Resource should have been excluded
30 - Resource should have been included

Non-Liquid Resources

Ø Element 221 - Real Property
Nature codes:
24 - Resource should have been excluded
30 - Resource should have been included

Ø Element 222 - Vehicles
Nature codes:
24 - Resource should have been excluded
30 - Resource should have been included

Ø Element 224 - Other Non-Liquid Resources
Nature codes:
24 - Resource should have been excluded
30 - Resource should have been included

Ø Element 225 - Combined Resources
Nature codes:
20 - Incorrect resource limit applied
29 - Exceeds prescribed limit

INCOME (300)
Earned Income
Ø Element 311 - Wages and Salaries
Nature codes:
32 - Failed to consider or incorrectly considered income of an ineligible member
35 - Unreported source of income (do not use for change in employment status)
36 - Rounding used/not used or incorrectly applied
38 - More income received from this source than budgeted
39 - Employment status changed from unemployed to employed
40 - Employment status changed from employed to unemployed
41 - Change only in amount of earnings
42 - Conversion to monthly amount not used or incorrectly applied
43 - Averaging not used or incorrectly applied
44 - Less income received from this source than budgeted
46 - Failed to consider/anticipate month with extra pay date
123 - Income incorrectly prorated

Ø Element 312 - Self-Employment
Nature codes:
32 - Failed to consider or incorrectly considered income of an ineligible member
35 - Unreported source of income (do not use for change in employment status)
36 - Rounding used/not used or incorrectly applied
38 - More income received from this source than budgeted
39 - Employment status changed from unemployed to employed
40 - Employment status changed from employed to unemployed
41 - Change only in amount of earnings
42 - Conversion to monthly amount not used or incorrectly applied
43 - Averaging not used or incorrectly applied
44 - Less income received from this source than budgeted
45 - Cost of doing business not used or incorrectly applied

Ø Element 314 - Other Earned Income
Nature codes:
32 - Failed to consider or incorrectly considered income of an ineligible member
35 - Unreported source of income (do not use for change in employment status)
36 - Rounding used/not used or incorrectly applied
38 - More income received from this source than budgeted
39 - Employment status changed from unemployed to employed
40 - Employment status changed from employed to unemployed
41 - Change only in amount of earnings
42 - Conversion to monthly amount not used or incorrectly applied
43 - Averaging not used or incorrectly applied
44 - Less income received from this source than budgeted
45 - Cost of doing business not used or incorrectly applied
Deductions

Ø Element 321 - Earned Income Deductions
Nature codes:
52 - Deduction that should have been included was not
53 - Deduction included that should not have been

Ø Element 323 - Dependent Care Deduction
Nature codes:
52 - Deduction that should have been included was not
53 - Deduction included that should not have been

Unearned Income
Ø Element 331 - RSDI Benefits
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 332 - Veterans Benefits
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 333 - SSI and/or State SSI Supplement
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 334 - Unemployment Compensation
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 335 - Worker's Compensation
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 336 - Other Government Benefits
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 342 - Contributions
Note: Errors in Child Support Payments should not be recorded in this Element. See Element
350 (Child Support Payments Received from Absent Parent).
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted

44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 343 - Deemed Income
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 344 - TANF, PA, or GA
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
120 - Variance/errors resulting from noncompliance with this means-tested public assistance
program
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 345 - Educational Grants/Scholarships/Loans
Nature codes:
35 - Unknown source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
124 - Variance resulting from use of automatic Federal information exchange system

Ø Element 346 - Other Unearned Income
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
120 - Variance/errors resulting from noncompliance with this means-tested public assistance
program
124 - Variance resulting from use of automatic Federal information exchange system

Element 350 - Child Support Payments Received from Absent
Parent
Nature codes:
35 - Unreported source of income
37 - All income from source was known but not included
38 - More income received from this source than budgeted
44 - Less income received from this source than budgeted
111 - Child support payment(s) not considered or incorrectly applied for initial month(s)of
eligibility
112 - Retained child support payment(s) not considered or incorrectly applied
124 - Variance resulting from use of automatic Federal information exchange system
127 - Pass through not considered or incorrectly applied

Ø Element 361 - Standard Deduction
Nature codes:
52 - Deduction that should have been included was not
53 - Deduction included that should not have been
65 - Incorrect standard used resulting from a change in household size

Ø Element 363 - Shelter Deduction
Nature codes:
52 - Deduction that should have been included was not
53 - Deduction included that should not have been
64 - Incorrect amount used resulting from a change in residence
123 - Incorrectly prorated

Ø Element 364 - Standard Utility Allowance
Nature codes:
52 - Deduction that should have been included was not
53 - Deduction included that should not have been
54 - Incorrect standard used (Not as a result of a change in household size or move)
64 - Incorrect amount used resulting from a change in residence
123 - Incorrectly prorated

Ø Element 365 - Medical Deductions
Nature codes:
52 - Deduction that should have been included was not
53 - Deduction included that should not have been

Ø Element 366 - Child Support Payment Deduction
Nature codes:
52 - Deduction that should have been included was not
53 - Deduction included that should not have been

Ø Element 371 - Combined Gross Income
Nature codes:
28 - Incorrect income limit applied
29 - Exceeds prescribed limit

Ø Element 372 - Combined Net Income
Nature codes:
28 - Incorrect income limit applied
29 - Exceeds prescribed limit

OTHER - (500 and 800)
Ø Element 520 - Arithmetic Computation
Nature codes:
75 - Benefit/allotment/eligibility incorrectly computed
79 - Incorrect use of allotment tables
80 - Improper proration of initial month's benefits

Ø Element 530 - Transitional Benefits
75 - Benefit/allotment/eligibility incorrectly computed
77 - Household not entitled to transitional benefits
99 - Other

Ø Element 560 - Reporting Systems
Note: This element should be used to record errors resulting from the household being certified
under an incorrect reporting system given the household's characteristics and the State agency's
chosen options. Possible Reporting Systems include: Monthly Reporting, Quarterly Reporting,
Semi-Annual Limited Reporting, Change Reporting, Status Reporting, 5 Hour Reporting and no
reporting (transitional benefits).
Nature codes:
301 - Household improperly participating under retrospective budgeting
302 - Household improperly participating under prospective budgeting
303 - Household improperly participating under monthly reporting
304 - Household improperly participating under quarterly reporting
305 - Household improperly participating under semi-annual reporting
306 - Household improperly participating under change reporting

307 - Household improperly participating under status reporting
308 - Household improperly participating under 5 hour reporting
309 - Household improperly participating in transitional benefits

Ø Element 810 - Food Stamp Simplification Project
Nature codes:
98 - Transcription or computation errors
99 - Other

Ø Element 820 - Demonstration Projects
Nature codes:
98 - Transcription or computation errors
99 - Other

14. Cause - Enter one of the following codes to indicate the primary cause for each variance
identified.

1 - Information not reported. (Client failed to report information or changes that are required
to be reported. Use this code only if the State could not know this information from
another source or could not have anticipated the change.)
2 - Incomplete or incorrect information provided. (Client provided information that is incorrect
or incomplete and the agency was not required to verify.)
3 - Information withheld by client. (Case being referred for IPV investigation.)
4 - Incorrect information provided by client. (Case being referred for IPV investigation.)
7 - Information reported by a collateral contact inaccurate. (The agency acted upon
information provided by a collateral contact, which was verified by QC to be inaccurate,
i.e. the client's employer reported incorrect salary information.)
8 - Acted on incorrect Federal computer match information that was not required to be
verified. (This variance is excluded from the error determination but must be recorded.)
10 - Policy incorrectly applied. (The agency used the wrong policy/incorrectly applied policy
when determining eligibility or processing change information.)
12 - Reported information disregarded or not applied. (The agency failed to take action on
information reported by the client or information that became known through some other
source, such as non-federal match information.)
14 - Agency failed to follow up on inconsistent or incomplete information. (Information
provided by the household or collateral source was inconsistent with other information in
the case record or incomplete but the agency failed to request verification.)
15 - Agency failed to follow up on impending changes. (The agency failed to take follow up
action on a change that was anticipated, i.e. unemployment ending within the
certification period, pregnancy, etc.)

16 - Agency failed to verify required information. (The agency failed to use third party
information or documentation to establish the accuracy of statements on the application or
change report form which are required to be verified. If the agency is not required to verify
reported information use code 2.)
17 - Computer programming error. (The agency eligibility system caused the error due to a
programming related problem, i.e. an incorrect amount for standard deduction was
programmed into the system, the agency authorized the use of workarounds to the
computer system that resulted in an error, etc.)
18 - Data entry and/or coding error. (The agency made a data entry error when keying into the
State/local agency eligibility system, includes selection of incorrect codes.)
19 - Mass Change. (The error was due to a problem with a computer generated mass change,
i.e. mass change was run late or incorrectly updated the case.)
20 - Arithmetic computation. (The agency made an error in computation or transcription, which
was not related to computer programming or data entry.)
21 - Computer user error. (The EW failed to use computer system properly or used an
unauthorized process to work around the system.)
99 - Other. (Variance caused by the agency, which does not fall under any of the specific
causes listed above.)

15.

Error Finding - (Optional). This item provides a means for reviewers to identify the impact

of individual variances. If only one variance is recorded for an error case, the error finding code
for this item and item 8, finding, should be the same. Enter the appropriate code for each
variance:
2 - Overissuance
3 - Underissuance
4 - Ineligible

16.

Error Amount - (Optional) Compute and enter the dollar amount of each separate variance.

If one variance is coded, then the amount in this item should be the same as the error amount
in item 10. If more than one variance is coded, the agency may use the optional guidance
provided in Chapter 12 or use State developed procedures for assigning dollar amounts. Some
agencies find this calculation helpful as an aid in prioritizing error causes for corrective actions.

17. Discovery - Enter one of the following codes to indicate how the variance was discovered:
1 - Variance clearly identified from case record: documentation is not from an automated match
2 - Variance clearly identified from case record: documentation is from an automated match
3 - Variance discovered from recipient interview
4 - Employer (present or former)
5 - Financial institution, insurance company, or other business
6 - Landlord
7 - Government agency or public records, not automated match
8 - Government agency or public records, automated match
9 - Other

18. Verified - Enter one of the following codes to indicate how the variance was verified:
1 - From case record: verification is not from an automated match
2 - From case record: verification is from an automated match
3 - From information provided by recipient
4 - Employer (present or former)
5 - Financial institution, insurance company, or other business
6 - Landlord
7 - Government agency or public records, not automated match
8 - Government agency or public records, automated match (may not apply to tax information)
9 - Other

19. Occurrence - Complete the following for each variance:
a.

Date - Enter the date (month and year) the variance occurred.

Time Period - Enter the appropriate code to indicate the time period during which
the variance occurred.

1 - Before most recent action by agency (The most recent action would be either a
certification or a recertification.)
2 - At time of most recent action by agency
3 - After the most recent action by agency
9 - Time of occurrence cannot be determined

SECTION 3 - HOUSEHOLD CHARACTERISTICS
This section collects information about the household's processing and specifics about resources,
income, and deductions that were the basis of their food stamp benefits.
Some specific items come from the case record (Items 20-24, and 26-27). These items are: most
recent action, type of action, length of certification period, allotment adjustment, amount of
adjustment, receipt of expedited service, and authorized representative.
For all other items use information from the final QC determination.

20.

Most Recent Certification Action - Enter the effective date (month, day and year) of

21.

Type of Action - Based on information in the case record, indicate the type of action by

the most recent certification or recertification action prior to or concurrent with the review
date. This date cannot be prior to the start of the most recent certification period and should
be in the case record.

entering one of the following codes:

1 - Certification
2 - Recertification
Certification means the first time a case has been certified or a certification action following
a break in participation.

Recertification means the initial certification period has expired and the agency has (a)
completed a reexamination of all factors of eligibility subject to change following a period of
time during which the recipient has been determined eligible and (b) made a decision to
continue eligibility.

22.

Length of Certification Period - Enter the number of months the household was

23.

Allotment Adjustment - This item records whether there was any adjustment from the

certified to participate during the current certification or recertification. For households that are
participating in months for which
they have not been certified enter the code 98. This information should be found in the case
record.

standard amount for the household size and income level of the household. Proration is
providing less than a full month's allotment due to the date of application or receipt of
verification. Other adjustments include claims recoupment, sanctions, and adjustments for
failure to comply with other means tested programs. Supplements included in the allotment
are not considered as allotment adjustments for this item.
Enter the code that indicates whether or not the allotment was adjusted or prorated. If more
than one adjustment was made, enter the code for the adjustment with the greatest impact on
the food stamp allotment. Supplements included in the allotment are not considered as
allotment adjustments for this item.
1 - No adjustment
2 - Prorated benefit
3 - Other adjustment

24.

Amount of Allotment Adjustment - Enter the amount of the allotment adjustment from

25.

Number of Household Members - Enter the number of person(s) determined to be a

the record. If more than one adjustment was applied, enter the total amount of the difference
between the allotment for the household size and income of the household and the amount the
household actually received. If item 23 is coded 1, no adjustment, leave this item blank. Enter
9 if the amount of adjustment is unknown.

part of the food stamp household and eligible to receive benefits based on the final QC
determination. Include persons who should have been in the household but were not in the
State's original determination. Do not include persons whose income/resources are
considered but are not receiving food stamps or food stamp household members who have
been

disqualified from the program. If the household was ineligible for benefits, enter zero.

26.

Receipt of Expedited Service - Using information from the case record, enter the
appropriate code for the household's entitlement to expedited service at the most recent
certification in effect at the time of the sample month:

1 - Entitled to expedited service and received benefits within the Federal timeframe.
2 - Entitled to expedited service but did not receive benefits within the Federal timeframe.
3 - Not entitled to expedited service.

27.

Authorized Representative Used at Application - Enter the appropriate code

using information from the case record. An authorized representative is a responsible adult
designated by the household, in writing, to apply for benefits on behalf of the household.
Did an authorized representative make application for the household?

1 - Yes
2 - No

28.

Categorical Eligibility Status - Was the household categorically eligible for benefits
based on the final QC determination?
1 - Yes
2 - No

29.

Reporting Requirement - Select the code that describes the reporting system used to

certify the household. If the household was certified under six-month reporting enter code
“6”, simplified reporting (also called six month reporting or semiannual reporting), even if QC
determined that the appropriate reporting system should have been something else.
1 - $25 change reporting
2 - $80 change in earned income
3 - $100 change in earned income
4 - Status reporting
5 - 5-hour change in hours worked and expected to continue over a month
6 - Simplified reporting (exceeding 130% of income poverty guidelines)
7 - Quarterly reporting

8 - Monthly reporting
9 - Transitional benefits (no reporting requirement)
10 - Other

Resources:
30.

Liquid Assets - Enter the dollar value of liquid assets such as cash on hand, checking and

savings accounts, money market accounts, stocks, bonds, income tax refunds using
information from the final QC determination. For amounts greater than $99,998 enter the code
99998. When there is an indication that a resource type was present but that amount is
unknown, enter the code 99999. If an approximate amount is known, enter that amount.

31. Real Property (Excluding Home) - Enter the dollar value of land and buildings owned,
excluding the primary residence using information from the final QC determination. For
amounts greater than $99,998 enter the code 99998. When there is an indication that a
resource type was present but that amount is unknown, enter the code 99999. If an
approximate amount is known, enter that amount.

32(a). Vehicle - Code information on up to two vehicles in items (a) and (b). Use information from
the final QC determination. Vehicles should be entered in descending order based on the
fair market value.

1 - No vehicles
2 - Vehicle exempt because used for producing income, as a home, to transport a physically
disabled member, for long distance travel (other than commuting), or to carry fuel or water.
3 - Vehicle exempt because inaccessible resource (equity value is $1,500 or less)
4 - Vehicle exempt due to categorical eligibility
5 - Vehicle excluded under State TANF standard (vehicle of non-categorically eligible
household members only)
6 - Vehicle is registered and is attributable to an adult household member or is used by a
person under 18 for employment or education (subject to fair market value only)
7 - Vehicle not registered (equity test only)
8 - Vehicle is not excluded and is not included in code 6 (subject to fair market value or equity
test, whichever is greater)

32(b). Status 2nd Vehicle - Use the codes 2 through 8 from 32(a).

33.

Countable Vehicle Assets - Record that portion of a vehicle's value counted toward the

34.

Other Non-liquid Assets - Enter the dollar value of non-liquid assets such as boats and

household's resource limit using information from the final QC determination.

trailers using information from the final QC determination. For amounts greater than $99,998
enter the code 99998. When there is an indication that a resource type was present but that
amount is unknown, enter the code 99999. If an approximate amount is known, enter that
amount.

Income:
35.

Gross Countable Income - Enter the countable gross monthly income of the Food Stamp

36.

Net Countable Income- Enter the countable net monthly income from the final QC

household before applying any deductions to the income from the final QC determination.
Enter all countable income. Include prorated amounts from ineligible household members.

determination used to compute the amount of the Food Stamp allotment for the sample month
after application of all appropriate deductions.

Deductions:
37.

Earned Income - Enter the amount of the earned income deduction that the household was

38.

Medical - Enter the amount of the allowable medical expenses for elderly and disabled

eligible to receive based on the final QC determination.

household members based on the final QC determination.

Do not record the value of the allowable medical deduction ($35). Enter those medical
expenses in excess of $35 per month.
For example, if a household was billed $100 for medical expenses, enter $65 ($100 minus the
medical deduction of $35).

39.

Dependent Care - Enter the total dependent care deduction to which the household was
entitled based on the final QC determination.

40.

Child Support - Enter the dollar value of the child support payment deduction from the final

41.

Shelter - Enter the dollar value of the shelter deduction from the final QC determination.

QC determination.

42. Homeless - Select the code that applies to this household based on the final QC determination.
1 - Not homeless
2 - Homeless, not receiving homeless shelter allowance
3 - Homeless, receiving homeless shelter allowance

Additional Information on Shelter Costs:
43.

Rent/Mortgage - Enter the amount the household was billed for rent/mortgage from the final

44.

Use of SUA - This entry has two boxes that are used to collect different information about the

QC determination. Include taxes, insurance, condo fees and homeowner association fees.

SUA. Do not complete 44(b) if 44(a) is coded 1.

a. Usage - Enter the code which describes usage and entitlement to the SUA based on the
final QC determination:

1 - No utilities and no LIHEAA
2 - Uses actual expenses
3 - Uses higher standard based on LIHEAA
4 - Uses higher standard and does not receive LIHEAA
5 - Uses lower standard
6 - Uses phone only standard
7 - Uses individual standards
9 - Other
LIHEAA is the Low Income Home Energy Assistance Act, your State program may have
another name such as Home Energy Assistance Program (HEAP)
Higher Standard is an SUA based upon receipt of heating or cooling and includes all utilities
Lower Standard is an SUA based upon all utilities but is for households who do not incur
heating or cooling or receive LIHEAA.

b. Proration - Select the code that identifies whether the SUA amount was prorated (e.g.
prorated among non-household members of the residence).
1 - Not prorated
2 - Prorated

45.

Utilities (SUA or Actual) - This item should be completed for all cases. For households

using actual utility expenses, enter the actual amount that was billed for all utilities (gas, water,
phone, electric, etc.) based on the final QC determination. For households using an SUA, enter
the amount of the SUA that was used, based on the final QC determination. Enter $0 if there
were no utility expenses.

SECTION 4 - INFORMATION ON EACH HOUSEHOLD MEMBER
Complete the following section, using information from the final QC determination, for eligible food
stamp households. Enter information on each household member, including individuals whose
income and resources were considered in establishing food stamp benefit level. If the number of
household members exceeds the number of lines available, attach an additional page to allow for
coding detailed person-level information on all food stamp household members. You may currently
enter information on up to 16 individuals on the automated system, but you may record information
on all household members using the paper form. If the entire household is ineligible do not enter any
information in this section.
For disqualified or ineligible food stamp household members, items 46, 47, 48, and 58, if applicable,
(person number, food stamp program participation, relationship to head of household, and dependent
care costs) of this section must be completed. Information on income for these members must also
be recorded in Section 5. For disqualified or ineligible members, the rest of the information in this
section should be completed based on information known through observation or available in the
case record.
NOTE: Do not enter zeros in items 48, 50-52, and 54-58 (Relationship to Head of Household, Sex,
Race, Citizenship Status, Employment Status, Work Registration, Employment and Training Program
Status, ABAWD Status, and Dependent Care Cost).

46.

Person Number - Assign and enter a number for each food stamp household member (1,

47.

Food Stamp Program Participation - For each person indicate his/her eligibility or

2, etc.). This will include ineligible food stamp household members whose resources and
income are considered in the eligibility determination. Use this assigned number to identify
household members with income in Section 5. Code the head of the household as person 1.

ineligibility for participation in the FSP (i.e., either eligible for participation and entitled to
benefits or a reason for ineligibility. For ineligible non-citizens, whether they participate in a
State funded FSP).

1 - Eligible member of Food Stamp case under review and entitled to receive benefits
2 - Reserved
3 - Reserved
4 - Member is an ineligible non-citizen and is not participating in a State funded FSP
5 - Member not paying/cooperating with Child Support agency
6 - Member is an ineligible striker
7 - Member is an ineligible student
8 - Member is disqualified for program violation
9 - Member is ineligible to participate due to disqualification for failure to meet work
requirements (work registration, E&T, acceptance of employment, employment status/job
availability, voluntary quit/reducing work effort, workfare/comparable and workfare).
10 - ABAWD time limit exhausted and the ABAWD is ineligible to participate due to failure to
meet ABAWD work requirements, to work at least 20 hours per week, to participate at
least 20 hours per week in qualifying educational training activities or to participate in
workfare.
11 - Fleeing felon or parole and probation violator
12 - Reserved
13 - Convicted drug felon
14 - Social Security Number disqualified
15 - SSI recipient in California.
16 - Prisoner in detention center
17 - Foster care
18 - Member is an ineligible non-citizen and is participating in a State-funded Food Stamp
Program.
99 - Unknown

48. Relationship to Head of Household - Enter the code that shows the relationship

(including by marriage) of the person indicated in item 46 (person number) to the head of
the household, as defined by the Food Stamp Program from final QC determination.
1 - Head of household
2 - Spouse
3 - Parent
4 - Daughter, stepdaughter, son, stepson
5 - Other related person (brother, sister, niece, nephew, grandchild, great-grandchild, cousin)
6 - Foster Child
7 - Unrelated person

49. Age - Enter the age (in years) from the final QC determination, of each household member. For
children less than 1 year old, enter 0. For persons 98 and older enter 98. If exact age is
unknown, enter the best available information.

50. Sex - Enter the appropriate code:
1 - Male
2 - Female

51. Race - Enter the race of each person living in the household.
This is to collect racial and ethnic data as required by the changes brought
about by the May 18, 2006 regulation Food Stamp Program: Civil Rights Data Collection and to
identify how to collect the information until the entire caseload has been converted to the new
requirement. The change to the new format may be done voluntarily at this time but is required for
all new applications and recertifications effective April 1, 2007. Under this scenario QC reviewers will
be recording the racial/ethnic data in the new format as soon as available and will be collecting the old
format from now through April 2009.
New format: Use codes 1 through 22 to record information if it has been collected in the new format.
Old format: Use codes 30 through 34 and 99 if the data is in the old format.
We expect the information will continue to be in the old format for most cases

until there are new applications and recertification after April 1, 2007. Due to
the way that recertifications are scheduled, cases will continue to have the old format until their
certification periods expire in the year following for most cases and 2 years for those elderly cases
with 24 month certification periods. This will mean that all cases will be in the new format on April 1,
2009.
Under the rules for the new format, applicants are asked to voluntarily fill out ethnicity and race on
their applications. Eligibility workers identify information for the applicant when they have not
voluntarily filled out the information. QC reviewers are to collect only the information that has been
recorded on the application.

New Format
Information Not Available
1 - The application was not found during the QC review therefore
racial/ethnic data is not available.
2 - Not recorded on the application for this individual.
Not Hispanic or Latino
3 - American Indian or Alaska Native
4 - Asian
5 - Black or African American
6 - Native Hawaiian or other Pacific Islander
7 - White
Multiple races reported
8 - (American Indian or Alaska Native) and White
9 - Asian and White
10 - (Black or African American) and White
11 - (American Indian or Alaska Native) and (Black or African American)
12 - Respondent reported more than one race and does not fit into the
above categories (code 8 through 11)

Hispanic or Latino
13 - (Hispanic or Latino) and (American Indian or Alaska Native)
14 - (Hispanic or Latino) and Asian
15 - (Hispanic or Latino) and (Black or African American)
16 - (Hispanic or Latino) and (Native Hawaiian or Other Pacific Islander)
17 - (Hispanic or Latino) and White
Multiple races reported
18 - (Hispanic or Latino) and (American Indian or Alaska Native) and White
19 - (Hispanic or Latino) and Asian and White
20 - (Hispanic or Latino) and (Black or African American) and White
21 - (Hispanic or Latino) and (American Indian or Alaska Native) and (Black or African American)
22 - (Hispanic or Latino) and Respondent reported more than one race and
does not fit into the above categories (code 18 through 21)

Old Format
These codes are for the recording of race based upon the older data collection requirements for those
cases where the new format has not yet been collected. Remember racial and ethnic data must be
collected in the new format for all new applications and recertifications above beginning April 1,
2007. Under the old data collection reviewers identify the racial/ethnic category of the members of the
household as they can by either asking the person being interviewed or through personal observation.
Racial/Ethnic Data Not Collected in the New Format
30 - White, not of Hispanic origin
31 - Black, not of Hispanic origin
32 - Hispanic
33 - Asian or Pacific Islander (Oriental)
34 - American Indian or Alaskan Native
99 - Unknown

52. Citizenship Status - Enter the appropriate code.
1 - U.S. born citizen
2 - Naturalized Citizen

3 - Legal permanent resident with 40 quarters, military service, five
years legal United States residency, disability, or under 18 years of
age.
4 - Reserved
5 - Person admitted as refugee, granted asylum or given a stay of
deportation.
6 - Other eligible non-citizen
7 - Non-citizen legally in US who does not meet one of the above codes
and who is not receiving food stamps but whose income and
resources must be considered in determining benefits
8 - Other ineligible legal non-citizen (e.g. visitor, tourist, student,
diplomat)
9 - Undocumented non-citizen
10 - Non-citizen, status unknown
99 - Unknown

53. Educational Level - Enter highest educational level completed for
each member of the household from the final QC determination:

0 - None
1 - Grade 1
2 - Grade 2
3 - Grade 3
4 - Grade 4
5 - Grade 5
6 - Grade 6
7 - Grade 7
8 - Grade 8
9 - Grade 9
10 - Grade 10
11 - Grade 11
12 - High school diploma or GED*
13 - Post secondary education (e.g. technical education or some college)
14 - College graduate or post-graduate degree
99 - Unknown
* If member attended grade 12 but did not graduate, use code 11.

54. Employment - Enter information on the current employment status of
all persons based on the final QC determination.

First box: Status
1 - Not in labor force and not looking for work
2 - Unemployed and looking for work
3 - Active duty military
4 - Migrant farm laborer
5 - Non-migrant farm laborer
6 - Self-employed, farming
7 - Self-employed, non-farming
8 - Employed by other

Second box: Hours Worked
1 - Not employed
2 - 1-19 hours per week
3 - 20-29 hours per week
4 - 30-39 hours per week
5 - 40+ hours per week

55. Food Stamp Program Work Registration - Enter information on
the current work registration status of all persons as known by the State
agency based on the final QC determination:
1 - Federal exemption for disability
2 - Federal exemption for a reason other than disability
3 - Work registrant, not employment and training (E&T) participant
4 - Work registrant, voluntary E&T participant
5 - Work registrant, mandatory E&T participant

56. Food Stamp Program (FSP) Employment and Training (E&T) Program Status Enter information on the current E&T program status of all household members as known by the
State agency based on the final QC determination:
0 - Not participating in E&T
1 - Participating in non-FSP E&T (such as TANF)
2 - FSP Job search or job search training
3 - FSP E&T workfare or work experience
4 - FSP E&T Work supplementation
5 - FSP E&T education leading to HS diploma or GED
6 - FSP E&T post secondary education leading to degree or certificate

7 - FSP E&T remedial education (including adult education and English lessons not leading to
a degree)
8 - FSP E&T vocational training
9 - Other

57.

ABAWD Status - A household member must be age 18 through 49 to be
an Able Bodied Adult Without Dependents (ABAWD). Enter one of the
following codes from the final QC determination:
1 - Not an ABAWD
2 - ABAWD in a waived area
3 - Exempt based on 15 percent option
4 - ABAWD meeting work requirements
5 - ABAWD in 1st 3 months
6 - ABAWD in 2nd 3 months

58. Dependent Care Cost - For each child/adult with associated dependent care expenses

enter the amount of the expense that the household is responsible for paying using information
from the final QC determination. If the cost for more than one child/adult is combined,
divide the cost evenly amongst each child/adult receiving care.

SECTION 5 - INCOME IDENTIFIED BY HOUSEHOLD MEMBER
This section collects detailed information on known income sources, by type and amount, based on
the final QC determination. Information can be collected on up to four sources of income for up to
ten household members. If income exists but is not attached to any specific member, assign the
income to the payee. Enter all income amounts rounded to the nearest dollar.

59. Person Number - Enter the person number from Section 4 for each

food stamp household member with income based on information from
the final QC determination. (This number is assigned in Section 4, item
46).

Source 1
60. Income Type - (This instruction applies to items 60, 62, 64, and 66).
Based on the final QC determination, identify the type of countable
income as listed below for each type of income received by a food
stamp household member.

Earned Income (Not Subsidized)
11 - Wages and salaries
12 - Self-employment
14 - Other earned income
Subsidized Earned Income
16 - Wage supplementation - enter earnings that are above cash
assistance and/or food stamp amount
Unearned Income
15 - Energy Assistance income
31 - RSDI benefits
32 - Veterans benefits
33 - SSI
34 - Unemployment Compensation
35 - Workmen's Compensation
36 - Other government benefits
37 - Foster care income
42 - Contribution
43 - Deemed income
44 - State general assistance or other State-funded welfare (don't
include TANF here)
45 - Educational grants/scholarships/loans
46 - Other
47 - TANF
48 - State only diversion payment
49 - Interest income
50 - Court ordered child support payments received from absent parent
or responsible person
99 - Unknown

61. Amount - (This instruction applies to Items 61, 63, 65, and 67.) Enter
the gross amount of countable income received by the food stamp
household member for the month from the final QC determination.

Source 2
62. Income Type - Second type of income. See item 60.
63. Amount - Second amount of income. See item 61.

Source 3
64. Income Type - Third type of income. See item 60.
65. Amount - Third amount of income. See item 61.
Source 4
66. Income Type - Fourth type of income. See item 60.
67. Amount - Fourth amount of income. See item 61.
SECTION 6 - RESERVED CODING
68.

Timeliness of Application Processing (Expedited and 30 Day Requirement This information is being collected for possible bonus payments. We want to delineate if there
was timeliness of application processing for cases when a new application was filled in the
current Federal Fiscal Year.
Timeliness of application processing is measured for cases that filed an application in the
current Fiscal Year. If there is more than one application in the current Fiscal Year, measure
timeliness for the most recent application for or prior to the sample month.
We are measuring the timeliness of application processing according to Federal processing
standards. A household entitled to expedited service must be provided the opportunity to
participate within 7 days. Households not entitled to expedited service must be provided the
opportunity to participate by the 30th day following the date of application. A case that meets
the applicable Federal processing standard is coded 1 - timely. A case that fails to meet the
applicable Federal processing standard is coded 2 - not timely.
If a new application was not filed in the review year, the case will not be used in determining
the bonus payment. The case should be coded 3 - Other. Also, use Code 3, for cases that
have been properly pended for incomplete verification. Improperly pended cases should be
coded 2 -not timely.

If after a thorough review of case circumstances and records there is no documentation,
application or other information to determine timeliness, the case should be coded 3. For cases
with this problem, every effort should be made to determine the timeliness of the case before
deciding to use the Other code.
Please indicate the appropriate code:
1 - Timely
2 - Not timely
3 - Other

69.

QC Interview - Enter the appropriate code from the following:
1 - Telephonic personal interview with household
2 - No Interview with household (likely conclusion) Failure or Refusal to
Cooperate
3 - No Interview with household (disposition incomplete) Failure or Refusal to
Cooperate
4 - No interview with household (disposition not subject to review)
5 - No interview with household (Ineligible determination prior to interview)
6 - Alaska - remote area no interview
7 - Alaska - telephone interview
8 - Face-to-face home visit
9 - Face-to-face in local office
0 - Face-to-face in mutually agreed upon location

70.

Recertification Timeliness

71.

Allotment Test - Enter the appropriate code that reflects which of the Allotment Tests

(Comparison I or Comparison II) has been recorded in Item #10. Enter one of the following codes:
1 - Comparison I recorded, Comparison II was not needed
2 - Did Comparison II, recorded Comparison I
3 - Did Comparison II, recorded Comparison II
4 - Comparison I equaled Comparison II
5 - Case ineligible, no Comparison I or Comparison II done

SECTION 7 - OPTIONAL FOR STATE USE
There are 4 lines of spaces available to the State to code additional information.

File Type	application/pdf
File Title	Quality Control Review Schedule
Subject	C:\DOCUME~1\Alice\LOCALS~1\Temp\_afg10b4q2a53d6pv.tmp
Author	Lisa Hibbitts
File Modified	2012-04-02
File Created	2012-04-02