Ap J_ QC-like Review Form (Approved under 0584-0029, 0584-0034)

Ap J_ QC-like Review Form.docx

Assessment of the Contribution of an Interview to SNAP Program Eligibility and Benefit Determination Study

Ap J_ QC-like Review Form (Approved under 0584-0029, 0584-0034)

OMB: 0584-0582

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0584-0582 can be found here:

2014-01-15 - No material or nonsubstantive change to a currently approved collection

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APPENDIX J – QC-LIKE REVIEW FORM

Mathematica Policy Research CFDA #: 10.588

OMB CONTROL #: 0584-0512

EXPIRATION DATE: 09/30/2012

QUALITY CONTROL-LIKE REVIEW SCHEDULE

PUBLIC BURDEN STATEMENT. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0584-0512. Public reporting burden for this collection of information is estimated to be 326 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA, 22302, ATTN: Rosemarie Downer

Section 1 – Review Summary

1. QC Review Number 2. Case Number 3. State 4. Local Agency 5. Sample Month and Year

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

6. Disposition 7. Findings 8. SNAP Allotment Under Review 9. Error Amount 10. Case Classification

| | | | | | | | | | | | | | | |

Section 2 – Detailed Error Findings

11. Element 12. Nature 13. Cause 14. Error Finding 15. Error Amount 16. Discovery 17. Verified 18. Occurrence

a. Date b. Time Period

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

Section 3 – Household Characteristics

19. Most Recent Cert. Action 20. Type of Action 21. Length of Cert. 22. Allotment Adjustment 23. Amount of

Month, Day, Year Period # of months Allotment Adjustment

| | | | | | | | | | | | | | | | | | | |

24. Number of Household 25. Receipt of Expedited 26. Authorized Representative 27. Categorical Eligibility 28. Reporting

Members Service Used at Application Requirement

| | | | | | | | | | | |

Resources:

29. Liquid 30. Property (excluding home) 31a. Vehicle 31b. Status 2nd Vehicle 32. Countable Vehicle Assets 33. Other Non-liquid

| | | | | | | | | | | | | | | | | | | | | | | | | | |

Income:

34. Gross 35. Net

| | | | | | | | | | |

Deductions:

36. Earned Income 37. Medical 38. Dependent Care 39. Child Support 40. Shelter 41. Homeless

| | | | | | | | | | | | | | | | | | | | | | | | | |

Additional Information on Shelter Costs: 42. Rent/Mortgage 43. Use of SUA 44. Utilities (SUA or Actual)

a. Usage b. Proration

| | | | | | | | | | | | | | |

Section 4 – Information on Each Household Member

45. Person 46. SNAP 47. Relation 48. Age 49. Sex 50. Race 51. Citizen 52. Edu. 53. Employment 54. ABAWD 55. Dependent

Number Participation to Head Status Level Status Hours Status Care

of HH Cost

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

You may include information for up to 16 individuals in the accompanying Excel spreadsheet.

Section 5 – Income Identified by Household Member

56. Person Source 1 Source 2 Source 3 Source 4

Number 57. Income 58. Amount 59. Income 60. Amount 61. Income 62. Amount 63. Income 64. Amount

Type Type Type Type

| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

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