Form FNS-742A FNS Independent Review Reporting Form

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

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Department of Agriculture, Food and Nutrition Service

Local Educational Agency Second Review of Applications Report
State agencies must report the information on this form ANNUALLY (By March 15th) for all local educational agencies (LEA) selected to
conduct a second review of Applications required under 7 CFR.245.11(b)(1)(i-iv).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains a valid OMB control
number. The valid OMB number for this collection is 0584-XXXX. The time required to complete this information collection is 15 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

State Agency:

SFA/LEA ID:

School Year:
From: 20__ To: 20__

SFA/LEA NAME:

1-1: Total number of schools in LEA:

1-2: Total number of enrolled students in LEAs:

1-3: Total number of applications:
Report all applications subject to second review

1-4: Total number of applications with changed
eligibility determinations:
Report all applications resulting in a changed
determination due to the second review process

1-3: Results of Second Review by Original Benefit Type
For each original benefit type (A, B, & C), report the number of applications for each result category (1, 2, & 3) and sub-categories (a, b, & c).
B. FREE-Income
Certified as FREE based on
income/household size application

A. FREE-Categorically Eligible
Certified as FREE based on documentation (e.g.
SNAP/TANF/FDPIR case number) on application

C. REDUCED PRICE-Income
Certified as REDUCED PRICE based on
income/household size application

1. NO CHANGE:

1. NO CHANGE:

1. NO CHANGE:

2. Changed to REDUCED PRICE:

2. Changed to REDUCED PRICE:

2. Changed to FREE:

a. Incomplete application error:

a. Incomplete application error:

a. Incomplete application error:

b. Categorical eligibility error:

b. Gross income calculation error:

b. Gross income calculation error:

c. Other error:

c. Other error:

c. Other error:

3. Changed to PAID:

3. Changed to PAID:

3. Changed to PAID:

a. Incomplete application error:

a. Incomplete application error:

a. Incomplete application error:

b. Categorical eligibility error:

b. Gross income calculation error:

b. Gross income calculation error:

c. Other error:

c. Other error:

c. Other error:

Form FNS-742a (01/14) Previous Editions are Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 version

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Additional Instructions for Reporting the FNS-742a

For the LEA selected for review, enter the State agency name, either the LEA or SFA identification code (only one code needed), name of LEA, and the
appropriate school year.
1-1: Total number of schools within LEA.
1-2: Total number of enrolled students in LEAs.
1-3: The total number of reviewed applications.
1-4: The total number of applications in the LEA whose eligibility determinations changed as a result of the Second Review of applications. Value should be
the sum of 1-3A2&3, B2&3, & C2&3.
1-5: Report the number of applications for each eligibility determination change category by original benefit type. For each application identify the
appropriate error source that resulted in the eligibility determination change. Error sources are as follows:
• Incomplete application errors include: lack of application signature, lack of SSN (last four digits), missing income value for household member(s),
missing case numbers (i.e. SNAP), and other missing information that is necessary for an eligibility determination.
• Categorical eligibility errors include: invalid case numbers, categorical eligibility claims known to be false, and invalid categorical standards.
• Gross income calculation errors include: incorrectly calculating household size, incorrectly determining the frequency of receipt of income, not
converting multiple income sources to annual income, not counting the child in the list of household members or counting the child twice,
incorrect arithmetic, misclassifying reportable income, and other income computation errors.
• Other errors include: any errors that are not included in the other categories that caused a change in eligibility determination or benefit level
during the second review of applications.
A1, B1, & C1: The total number of applications, by benefit type, that did not result in a change in eligibility determination or benefit level.
A2 & B2: The total number of applications, by benefit type, that changed to Reduced Price due to the second review. Values should equal the sum
of their respective sub-categories (a, b, & c).
A2a-c & B2a-c: The number of applications with changes in eligibility determination or benefit level by each error type.
C2: The total number of applications changed to Free due to the second review. Value should equal the sum of sub-categories
(a, b, & c).
A3, B3, & C3: The total number of applications, by benefit type, changed to Paid due to the second review. Values should equal the sum of the
sub-categories (a, b, & c).