Fns 366b Program And Budget Summary Statement Part B - Program Ac

OMB Control Number 0584-0083
Expiration Date xx/xx/xxxx

Appendix E FNS 366B Form

Form Approved OMB No. 0584-0594
Expiration Date: 07/31/2023

Print
1. STATE

U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE

2. REPORT PERIOD

PROGRAM AND BUDGET SUMMARY STATEMENT
PART B - PROGRAM ACTIVITY STATEMENT
CERTIFICATIONS

(a) APPROVALS

(b) DENIALS

TO

(c) TOTAL APPROVED
AND DENIED

MONTH

YEAR

MONTH

YEAR

(d) 1-30 DAYS

APPROVED OVERDUE APPLICATIONS
(e) 31-60 DAYS
(f) 61-90 DAYS

(g) 91+ DAYS

3. INITIAL APPLICATIONS
4. RECERTIFICATIONS
5. TOTAL
6a. EXPEDITED SERVICE – INITIAL
APPLICATIONS
6b. EXPEDITED SERVICE RECERTIFICATIONS
FAIR HEARINGS

(a) HEARINGS
REQUESTED

(b) HEARINGS
HELD

(c) DECISIONS
UPHELD

(d) DECISIONS
REVERSED

(e) DECISIONS
OVERDUE

(f) WITHDRAWN
REQUESTS

7. ACTIVITY
ELIGIBILITY FRAUD
(b)
NO
(a) EVIDENCE
(c) RESULTED (d) AVERAGE #
FRAUD
EVIDENCE
IN REFERRAL OF DAYS PER
(e) OPEN
INVESTIGATIONS FOUND TO
FOUND
TO
REDUCE OR
FOR ADH OR CONCLUDED
INVESTIG AT IO N S
REDUCE
OR
DENY BENEFITS DENY BENEFITS PROSECUTION INVESTIGATION
8. CASES/DAYS/
HOURS
ELIGIBILITY FRAUD

TRAFFICKING
(f) RESULTED
IN REFERRAL
FOR ADH OR
PROSECUTION

(g) RESULTED IN
NO REFERRAL
FOR ADH OR
PROSECUTION

COMBINED

(h) AVERAGE #
(j)
OF DAYS PER
(i) OPEN
CONCLUDED
INVESTIG AT IO N S INVESTIGATOR
HOURS
INVESTIGATION

TRAFFICKING

COMBINED

(c) ADH
(g) ADH
ADMINISTRATIVE
(a) ADH
(b) WAIVER CONCLUDED,
(e) ADH
(f) WAIVER CONCLUDED,
(d) AMOUNT CONCLUDED,
(h) AMOUNT
DISQUALIFICATION CONCLUDED,
SIGNED,
SIGNED,
SUBJECT INDIVIDUAL
INDIVIDUAL
SUBJECT
HEARINGS
INDIVIDUAL
INDIVIDUAL INDIVIDUAL
INDIVIDUAL
NOT
TO CLAIM DISQUALIFIEDDISQUALIFIED
NOT
TO CLAIM
DISQUALIFIED DISQUALIFIED DISQUALIFIED
DISQUALIFIED

REFERRED INDIVIDUALS
AWAITING SCHEDULING
(i)
91-180 DAYS

(j)
181+ DAYS

(k) DECISION
NOTICES
OVERDUE

9. INDIVIDUALS/
$/NOTICES
ELIGIBILITY FRAUD
(a) PROSECUTION (b) DCA SIGNED, (c) PROSECUTION
PROSECUTIONS CONCLUDED,
CONCLUDED,
INDIVIDUAL
INDIVIDUAL
INDIVIDUAL NOT
DISQUALIFIED
DISQUALIFIED
DISQUALIFIED
10. INDIVIDUALS/
$/DAYS

FNS-366B (Quarterly) (10/22) Previous Editions
Obsolete

(d) AMOUNT
SUBJECT
TO CLAIM

TRAFFICKING
(e) PROSECUTION (f) DCA SIGNED, (g) PROSECUTION
CONCLUDED,
CONCLUDED,
INDIVIDUAL
INDIVIDUAL
INDIVIDUAL NOT
DISQUALIFIED
DISQUALIFIED
DISQUALIFIED

SBU

(h) AMOUNT
SUBJECT
TO CLAIM

COMBINED
(i) AVERAGE # OF
DAYS PER
CONCLUDED
PROSECUTION

Electronic Form Version Designed in Adobe 10.0 Version