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OMB APPROVED NO. 0584-0594 |
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Expiration Date: XX/XX/XXXX |
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| U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE |
1. STATE |
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| PROGRAM AND BUDGET SUMMARY STATEMENT |
2. REPORT PERIOD |
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| PART B - PROGRAM ACTIVITY STATEMENT |
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TO |
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MONTH |
YEAR |
MONTH |
YEAR |
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| CERTIFICATIONS |
(a) APPROVALS |
(b) DENIALS |
(c) TOTAL APPROVED AND DENIED |
APPROVED OVERDUE APPLICATIONS |
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| (d) 1 - 30 DAYS |
(e) 31 - 60 DAYS |
(f) 61 - 90 DAYS |
(g) 91+ DAYS |
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| 3. INITIAL APPLICATIONS |
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| 4. RECERTIFICATIONS |
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| 5. TOTAL |
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| 6a. EXPEDITED SERVICE - INITIAL APPLICATIONS |
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| 6b. EXPEDITED SERVICE - RECERTIFICATIONS |
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| FAIR HEARINGS |
(a) HEARINGS REQUESTED |
(b) HEARINGS HELD |
(c) DECISIONS UPHELD |
(d) DECISIONS REVERSED |
(e) DECISIONS OVERDUE |
(f) WITHDRAWN REQUESTS |
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| 7. ACTIVITY |
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| FRAUD INVESTIGATIONS |
ELIGIBILITY FRAUD |
TRAFFICKING |
COMBINED |
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| (a) EVIDENCE FOUND TO REDUCE OR DENY BENEFITS |
(b) NO EVIDENCE FOUND TO REDUCE OR DENY BENEFITS |
(c) RESULTED IN REFERRAL FOR ADH OR PROSECUTION |
(d) AVERAGE # OF DAYS PER CONCLUDED INVESTIGATION |
(e) OPEN INVESTIGATIONS |
(f) RESULTED IN REFERRAL FOR ADH OR PROSECUTION |
(g) RESULTED IN NO REFERRAL FOR ADH OR PROSECUTION |
(h) AVERAGE # OF DAYS PER CONCLUDED INVESTIGATION |
(i) OPEN INVESTIGATIONS |
(j) INVESTIGATOR HOURS |
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| 8. CASES / DAYS / HOURS |
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| ADMINISTRATIVE DISQUALIFICATION HEARINGS |
ELIGIBILITY FRAUD |
TRAFFICKING |
COMBINED |
| (a) ADH CONCLUDED, INDIVIDUAL DISQUALIFIED |
(b) WAIVER SIGNED, INDIVIDUAL DISQUALIFIED |
(c) ADH CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(d) AMOUNT SUBJECT TO CLAIM |
(e) ADH CONCLUDED, INDIVIDUAL DISQUALIFIED |
(f) WAIVER SIGNED, INDIVIDUAL DISQUALIFIED |
(g) ADH CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(h) AMOUNT SUBJECT TO CLAIM |
REFERRED INDIVIDUALS AWAITING SCHEDULING |
(k) DECISIONS NOTICES OVERDUE |
| (i) 91-180 DAYS |
(j) 181+ DAYS |
| 9. INDIVIDUALS / $ / NOTICES |
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| PROSECUTIONS |
ELIGIBILITY FRAUD |
TRAFFICKING |
COMBINED |
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| (a) PROSECUTION CONCLUDED, INDIVIDUAL DISQUALIFIED |
(b) DCA SIGNED, INDIVIDUAL DISQUALIFIED |
(c) PROSECUTION CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(d) AMOUNT SUBJECT TO CLAIM |
(e) PROSECUTION CONCLUDED, INDIVIDUAL DISQUALIFIED |
(f) DCA SIGNED, INDIVIDUAL DISQUALIFIED |
(g) PROSECUTION CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(h) AMOUNT SUBJECT TO CLAIM |
(i) AVERAGE # OF DAYS PER CONCLUDED PROSECUTION |
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| 10. INDIVIDUALS / $ / DAYS |
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OMB APPROVED NO. 0584-0594 |
|
|
|
|
|
|
|
|
|
Expiration Date: XX/XX/XXXX |
|
| U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE |
1. STATE |
|
|
| PROGRAM AND BUDGET SUMMARY STATEMENT |
2. REPORT PERIOD |
|
|
|
|
|
|
| PART B - PROGRAM ACTIVITY STATEMENT |
|
|
|
TO |
|
|
|
|
|
|
|
|
MONTH |
YEAR |
MONTH |
YEAR |
|
|
|
|
|
|
|
|
|
|
|
|
|
| CERTIFICATIONS |
(a) APPROVALS |
(b) DENIALS |
(c) TOTAL APPROVED AND DENIED |
APPROVED OVERDUE APPLICATIONS |
|
|
|
|
| (d) 1 - 30 DAYS |
(e) 31 - 60 DAYS |
(f) 61 - 90 DAYS |
(g) 91+ DAYS |
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|
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| 3. INITIAL APPLICATIONS |
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| 4. RECERTIFICATIONS |
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| 5. TOTAL |
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| 6. EXPEDITED SERVICE |
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| FAIR HEARINGS |
(a) HEARINGS REQUESTED |
(b) HEARINGS HELD |
(c) DECISIONS UPHELD |
(d) DECISIONS REVERSED |
(e) DECISIONS OVERDUE |
(f) WITHDRAWN REQUESTS |
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| 7. ACTIVITY |
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| FRAUD INVESTIGATIONS |
ELIGIBILITY FRAUD |
TRAFFICKING |
COMBINED |
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| (a) EVIDENCE FOUND TO REDUCE OR DENY BENEFITS |
(b) NO EVIDENCE FOUND TO REDUCE OR DENY BENEFITS |
(c) RESULTED IN REFERRAL FOR ADH OR PROSECUTION |
(d) AVERAGE # OF DAYS PER CONCLUDED INVESTIGATION |
(e) OPEN INVESTIGATIONS |
(f) RESULTED IN REFERRAL FOR ADH OR PROSECUTION |
(g) RESULTED IN NO REFERRAL FOR ADH OR PROSECUTION |
(h) AVERAGE # OF DAYS PER CONCLUDED INVESTIGATION |
(i) OPEN INVESTIGATIONS |
(j) INVESTIGATOR HOURS |
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| 8. CASES / DAYS / HOURS |
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| ADMINISTRATIVE DISQUALIFICATION HEARINGS |
ELIGIBILITY FRAUD |
TRAFFICKING |
COMBINED |
| (a) ADH CONCLUDED, INDIVIDUAL DISQUALIFIED |
(b) WAIVER SIGNED, INDIVIDUAL DISQUALIFIED |
(c) ADH CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(d) AMOUNT SUBJECT TO CLAIM |
(e) ADH CONCLUDED, INDIVIDUAL DISQUALIFIED |
(f) WAIVER SIGNED, INDIVIDUAL DISQUALIFIED |
(g) ADH CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(h) AMOUNT SUBJECT TO CLAIM |
REFERRED INDIVIDUALS AWAITING SCHEDULING |
(k) DECISIONS NOTICES OVERDUE |
| (i) 91-180 DAYS |
(j) 181+ DAYS |
| 9. INDIVIDUALS / $ / NOTICES |
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| PROSECUTIONS |
ELIGIBILITY FRAUD |
TRAFFICKING |
COMBINED |
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| (a) PROSECUTION CONCLUDED, INDIVIDUAL DISQUALIFIED |
(b) DCA SIGNED, INDIVIDUAL DISQUALIFIED |
(c) PROSECUTION CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(d) AMOUNT SUBJECT TO CLAIM |
(e) PROSECUTION CONCLUDED, INDIVIDUAL DISQUALIFIED |
(f) DCA SIGNED, INDIVIDUAL DISQUALIFIED |
(g) PROSECUTION CONCLUDED, INDIVIDUAL NOT DISQUALIFIED |
(h) AMOUNT SUBJECT TO CLAIM |
(i) AVERAGE # OF DAYS PER CONCLUDED PROSECUTION |
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| 10. INDIVIDUALS / $ / DAYS |
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