ATTACHMENT B1b - Case Record Review Template

OMB NUMBER: 0584-XXXX

EXPIRATION DATE: XX-XX-20XX

ATTACHMENT B1b: CASE RECORD REVIEW TEMPLATE

BURDEN DISCLOSURE 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-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS: CASE RECORD REVIEW FORM ^{OMB CONTROL NUMBER: xxxxxxx}

RELATIONSHIP TO FDPIR APPLICANT

AGE

SNAP (FOOD STAMPS)

INCOME (EARNED AND UNEARNED)

SELF‐EMPLOYMENT INCOME

STUDENTS

RESOURCES

Receiving?

Applied for?

Disqualified?

Source 1: Income Type

Amount

Source 2: Income Type

Amount

Source 3: Income Type

Amount

Source 4: Income Type

Amount

Household Member Self‐ Employed

Type of Business

Occupation

Primary Source of Income?

Student Receiving Financial Aid?

Amount of Loan/Grant

Time Period

Type of Student Aid

Amount Used for Tuition/Fees

Cash on Hand

Checking/ Savings Account *

Stock/Bonds/ CDs/Other

Y/N

Y/N

Y/N

Enter $ amount

Enter $ amount

Enter $ amount

Enter $ amount

Y/N

Y/N/NA

Y/N

Enter $ amount

Enter begin date

Enter end date

Enter all that apply. Add rows as needed

Enter $ amount

Enter $ amount

Enter $ amount

Enter $ amount

1

self

Y/N/NA

2

Y/N/NA

3

Y/N/NA

4

Y/N/NA

5

Y/N/NA

6

Y/N/NA

7

Y/N/NA

8

Y/N/NA

9

Y/N/NA

10

Y/N/NA

11

Y/N/NA

12

Y/N/NA

13

Y/N/NA

14

Y/N/NA

15

Y/N/NA

16

Y/N/NA

Relationship to FDPIR Applicant Income Self‐Employment Income Type of Student Aid * Note:

A Spouse A Social Security A Rental Property A Pell Grant

B Partner B SSI B Roomers B Student Loan

C Son C TANF C Boarders C BIA

D Daughter D General/Public Assistance D Farming D Scholarship

E Step‐child E Foster Care Payments E Ranching E Other: F Foster‐child F Unemployment Insurance F Own business

G Mother G Worker's Compensation G Other:

H Step‐mother H Child Support

I Father I Alimony

J Step‐father J Pensions

K Brother K Veteran's Benefits

L Sister L Per capita payments

M Grandmother M Work/training allowances

N Grandfather N Other:

O Aunt O No income source

P Uncle Q Cousin R Niece

S Nephew

T Mother‐in‐law

U Father‐in‐law

V Sister‐in‐law

W Brother‐in‐law

X Other‐in‐law

Y Roomer/boarder

Z Other non‐relative

Information will be abstracted exactly as it appears in the case file. Joint savings and checking accounts will be attributed to individuals or divided across individuals as recorded on the case file.

Case Record Review data abstraction done by [NAME]

Abstraction date: [MM/DD/YYY] ^{[Page X of Y]}

Quality Control review conducted by: [NAME], [MM/DD/YYYY]

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