Form 380-1 Quality Control Review Schedule

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

APPENDIX A- OMB 0584-0299

0MB APPROVED NO. 0584-0299
Expiration Date:XX/XX/XXXX

QUALITY CONTROL REVIEW SCHEDULE
Public reporting burden for this collection of information is estimated to average 1.056 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may
not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid 0MB control
number. 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 Policy Support, Room 1014, Alexandria, VA 22032 ATTN: PRA
(0584-0299). Do not return the completed form to this address. This report is required under provisions of 7 CFR 275.24. 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.
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Section 1 - Review Summary
1. QC Review Number

7. Disposition

2. Case Number

8. Findings

D

3. State

4. Local Agency

D

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9.SNAP Allotment Under Review

5. Sample Month and Year

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6. Stratum

D

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10. Error Amount

11. Case Classification

D

D
Section 2 -: Detailed Error Findings

12. Element
1

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2

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31

4

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5

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13. Nature

14. Cause

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61

7

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FORM FNS-380-1 (05-19) Previous Editions Obsolete

D
D
D
D
D
D
D

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15. Error Finding 16. Error Amount

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D
D
D
D
D
D
D

17. Discovery

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SBU

D
D
D
D
D
D
D
D

18. Verified

19. Occurrence
a. Date

D I
D I
D I
D I
D I
D I
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D I

b. Time Period

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Electronic Form Designed in AEM 6.4 Version

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

25. Number of
Household Members

21. Type of Action

22. Length of Cert. Period
#of months

D
26. Receipt of
Expedited Service

D
27. Authorized Representative
Used at Application

D

D

23. Allotment Adjustment

D

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28. Categorical Eligibility

D

24. Amount of
Allotment Adjustment

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29. Reporting Requirement

D

D

Resources:
30. Liquid

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32a. Vehicle

31. Property
(excluding home)

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32b. Status
2nd Vehicle

D

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33. Countable
Vehicle Assets

34. Other Non-liquid

D

Income:
35. Gross

36. Net

Deductions:
37. Earned Income

38. Medical

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Additional
Information on
Shelter Costs:

43. Rent/Mortgage

39. Dependent Care

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44. Use of SUA
a. Usage
b. Proration

41. Shelter

40. Child Support

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42. Homeless

D

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45. Utilities (SUA or Actual)

DD

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

47. SNAP
48. Relation
Participation
to Head
ofHH

DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD
DD

49. Age

50. Sex

51. Race

52. Citizen
Status

53. Edu.
Level

54. Employment
Status
Hours

D D • DDD •••
D D • DDD •••
DD D DD DD ••
D D • DDD •••
D D • WDD •••
D D • DDD •••
D D • DDD •••
D D • DDD •••
D D • DDD •••
D D • DDD •••
D D • DDD •••
D D • DDD •••

55. SNAP
56. SNAP
Work Reg. . E & T

D
D
D
D
D
D
D
D
D
D
D
D

57. ABAWD 58. Dependent
Status
Care Cost

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D11111
DI 111 I
D11111
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D11111
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D11111
D11111
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You may record information on up to 16 individuals using additional pages.

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

GJ
GJ
GJ
GJ
GJ

Source 1
60. Income Type

Source 2
62. Income Type

61. Amount

GJ
GJ
GJ
GJ
GJ

63. Amount

Source 4
66. Income Type

65. Amount

GJ
GJ
GJ
GJ
GJ

GJ
GJ
GJ
GJ
GJ

I

Source 3
64. Income Type

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

GJ
GJ
GJ
GJ
GJ

67. Amount

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Section 6 - Reserved Coding
68.

69.

70.

71.

72.

73.

74.

75.

76.

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Section 7 - Optional For State Use
1.
2.

3.
4.

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