State and Local Burden - SA, SFA/LEA

Attachment N.21. Seamless Summer Option Eligibility Certification Form (SSO S-2)

This information is being collected from State agencies, school food authorities, schools. This is a revision of a currently approved
information collection. The Richard B. Russell National School Lunch Act (NSLA) 42 U.S.C. § 1758, as amended, authorizes the National
School Lunch Program (NSLP). This information is required to administer and operate this program in accordance with the NSLA. Under the
Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork
Reduction Act of 1995, 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 valid OMB control number for this information collection is 0584-0006. The time required to
complete this information collection is estimated to average 47.5 hours of reporting burden per response. The burden consists of the time it
takes for the State agency to conduct the off-site portion of the review which includes scheduling of the review and the completion of the Offsite Assessment, Resource Management Risk Indicator, and Site Selection Tools. 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, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0006). Do not
return the completed form to this address.

OMB #0584-0006

SEAMLESS SUMMER OPTION ELIGIBILITY CERTIFICATION AND BENEFIT ISSUANCE ERROR WORKSHEET (SSO S-2)
SFA:
ELIGIBILITY CERTIFICATION ERRORS

APPLICATIONS
MISSING INFORMATION

STUDENT

ELIG
STATUS
F/R

START
DATE
OF
ERROR

[√]
IF
DIR
CT

[√]
IF
DOC
ELIG

CH
HH
NM

CS
#

INC
AMT
SRC

SS
#

[ ] ENROLLED SITE

[ ] CAMP

BENEFIT ISSUANCE ERRORS

PS 1
VIOL.

F/
R

F/
D

R/
D

[ ] IF
100%

INELIG
RECEIV

APPLICATIONS
MISCATEGORIZED

AD
SIG

NA [ ]

Expiration Date xx/xx/20xx

R/
F

RED
REC
FRE

FRE
REC
RED

→R
→D
R→D
R→F
F

F

R

F

DATE
OF
CORRECTION

[√ ] IF
VERIFIED

If the application has missing information only, do not check any boxes under miscategorized.
COUNT OF REVIEWED STUDENTS
COMMENTS:

FOR STEP 3 OF FA WORKBOOK

FOR STEP 4 OF FA WORKBOOK

SFA COUNT OF REVIEWED STUDENTS

SA COUNT OF REVIEWED STUDENTS

FREE AND REDUCED PRICE TOTAL

_______

FREE AND REDUCED PRICE TOTAL

_______

REVIEWER:

SSO Eligibility Certification Form SSO S-2

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Last updated School Year 2017-2018

SSO Eligibility Certification Form SSO S-2

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Last updated School Year 2017-2018

ELIGIBILITY CERTIFICATION AND BENEFIT ISSUANCE ERROR WORKSHEET –SSO S-2
GENERAL
COMMENTS
This form is to be used to record errors identified during the review of certification and
benefit issuance. Only list reviewed students in error. Other household members
certified in error whose eligibility must be corrected are listed on Form SFA-2.
The worksheet must be completed for both the 100 % review of eligibility certifications
and the statistical sample method. A copy of the completed worksheet will be provided
to the LEA so that corrective action on each error can be implemented. If the review did
not identify errors, check [] NA.
LEA

Enter the name of the local educational agency. Check if SFA has an enrolled site or
camp.

STUDENT

The student’s name or other identifier such as a student identification number or
application number is recorded in this space. When an identifier other than the
student’s name is used, adequate information must be provided to the LEA/school to
identify the student(s) in error for corrective action purposes.

ELIGIBILITY
DETERMINATION

free (F) or reduced-price (R).

START DATE
OF ERROR

If there is no date on the eligibility certification document, attempt to determine the
date or approximate date of approval. This may be accomplished by asking the
individual(s) responsible for the maintenance of the documents to provide an approval
date, or by using the date the application was signed by the parent or received by the
LEA/school. If direct certification, enter the date the certification was made. If it is not
possible to determine an approval date, the document may still be considered valid for
the time period being reviewed. In those situations where the start date of error is not
known, enter a dash (-) in the space.

DIRECT
CERTIFICATION

Enter [] if the student was directly certified.

ELIGIBILITY
BASED ON
DOCUMENTATION

Enter [] if the student was determined eligible for free meal benefits based on
migrant, homeless, runaway, Headstart, foster child or EvenStart status.

TYPE OF
ERROR

Check the space(s) which identifies each type of application or benefit issuance error.
More than one error may be identified for a student.

SSO Eligibility Certification Form SSO S-2
Last updated School Year 2017-2018

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MISSING
INFORM
ATION

Check the space that includes the missing information. Incomplete applications errors
include missing child or household name (CH HH NM), lack of adult signature (AD SIG),
lack of social security number last four digits (SS#) , missing income amount or source
(INC AMT SRC), missing case numbers (CS #) , or other missing information that is
necessary for an eligibility determination.

MISCATEGORIZED

Miscategorized applications 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. Indicate the miscategorization, F/R, F/D, R/D or R/F.

BENEFIT
ISSUANCE
ERRORS

Compare the eligibility certification documents (i.e., household applications, direct
certification, other categorically eligible student documentation) to the benefit issuance
document(s) used at the point of service to ensure students are receiving the benefits
for which they were approved.
An error exists when a free or reduced-price student is listed on the benefit issuance
document in an eligibility category other than the category for which that student was
approved, regardless of the correctness of the approval, or the LEA does not have
proper documentation for a student receiving free or reduced-priced benefits.
When an error is found in eligibility certification that is offset by an error in benefit
issuance, neither error contributes to a Performance Standard 1 violation or results in
fiscal action. For example, when a student is incorrectly certified for free benefits but
should have received reduced-price benefits and is listed on the BI document as
reduced-price, there is no error in Performance Standard 1. However, corrective action
must be completed.

PS 1
VIOLATIONS
DATE OF
CORRECTION

For each student listed on the worksheet, determine if the error was caused by a free or
reduced- price student being listed incorrectly on the BI roster.
Technical assistance and corrective action will be required for all benefit issuance errors.
Corrective action will be applied to all schools to ensure that previously deficient
practices and procedures are revised system-wide. Corrections will be made to the
eligibility of other affected household members when discovered during administrative
review. As mentioned, record these names on form SFA-2.
Documented corrective action is required for any degree of violation in an
administrative review. This may be completed at the time of the review; however, it
shall be postmarked or submitted to the SA no later than 30 days from the deadline for
completion of each required corrective action. The SA shall maintain any documented
corrective action on file for review by FNS.

[ ] 100%

Check if 100 % of the eligibility determinations is reviewed.

SSO Eligibility Certification Form SSO S-2
Last updated School Year 2017-2018

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[√] IF VERIFIED

Check if this students application was verified. This application counts toward the 10%
verification sample. Record the verification also on SFA-2 under “Verification Errors.”

COMMENTS

Enter appropriate comments related to eligibility certification, benefit issuance and
corrective action.

FISCAL
ACTION

Based on the review of the eligibility determinations and basis of issuance
documentation from the statistically valid sample or the 100 % review, the reviewer will
determine the information to be transferred to the Fiscal Action Workbook.
The State agency must establish a count of the total number of reviewed students that
the SFA certified for free meals and reduced-price meals. This is either the statistically
valid sample or the total free and reduced price students when 100 % of the names are
reviewed.
The State agency must establish its own validated count of the correct total number of
reviewed students certified for free meals and reduced-price meals.

SSO Eligibility Certification Form SSO S-2
Last updated School Year 2017-2018

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