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Appendix H- OMB 0584-0299
SNAP- QC System's electronic version of the FNS 380-1

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O - Original

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Status:

.____s_a_v_ e___l,LI _E_d_ i_t _C_h_e_c_k_.l,I__
A_ p_p _ro_v _ e___.ll.____D_e_le_ t_e____,I ....___
I
Q_u_i t___.

FNS380 1 FNS380-1 I
1
Sections 1 and 2 11 Sect....i_on
_ 3
_ -.I I Sections 4 and 5 11 Section 6 11 Section 7 I
Section I - Review Summary
I . QC Review Number

2. Case Number

4. Local Agency

3. State

5. Sample Month and Year

6. Stratum

202110
7. Disposition

8. Review Finding

9. SNAP Allotment Under Review

I I .Case Classification

I 0. Error Amount

Section 2 - Detailed Error Findings
12. Element

13. Nature Codes

14. Cause

15. Error
Finding

16. Error Amount

17. Discovery

18. Verification

19a

Occurrence
Date (Month)

19a

Occurrence
Date (Year)

19b

Occurrence
(Time Period)

Insert Line

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Case Information (QC Review Number: 999999)
Revision:

Status:

O - Original

New File

I
.____s_a_v_ e___l,LI _E_d_ i_t _C_h_e_c_k_.l,__
Q_u_i t___.
A_ p_p _ro_v _ e___.l l....__D_e_le_ t_e____.l l....___
FNS 380

FNS 380-1

Sections 1 and 2

Section 3

Sections 4 and 5

Section 6

Section 7

Section 3 - Household Characteristics

20. Most Recent Action
(MM/DD/YYYY)

21. Type of Action

25. Number of
Household Members

26. Receipt of
Expedited Service

22. Length of Certification Period

# of months

27. Authorized Representative
Used at Certification

23. Allotment Adjustment

24. Amount of Allotment Adjustment

28. Categorical Eligibility

29. Reporting Requirement

Resources:

3 I . Real Property
(Excluding Home)

30. Liquid Assets

32 a. I st Vehicle
Status

32 b. 2nd Vehicle
Status

33. Countable Vehicle Assets

34. Other Non-Liquid Assets

Income:

35. Gross Countable Income

36. Net Countable Income

Deductions:

37. Earned Income Deduction

38. Medical Cost Deduction

39. Dependent Care Cost
Deduction

43. Rent/Mortgage

Additional
https://snapqcs-test.fns.usda.gov/OnlineReview/Caselnformation.aspx

40. Child Support Payment Deduction

44. Use of Standard Utility Allowance
a. Usage

b. Proration

42. Homeless
Shelter

41. Shelter Deduction

45. Utilities (SUA or Actual)
01

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Case Information (QC Review Number: 999999)
Revision:

Status:

O - Original

New File

.____s_a_v_ e___l,LI _E_d_ i_t _C_h_e_c_k_.l,I__
A_ p_p _ro_v _ e___.ll.____D_e_le_ t_e____,I ....___
I
Q_u_i t___.

FNS380 1 FNS380-1 I
1
Sections 1 and 2 11 Sect....i_on
_ 3
_ -.I I Sections 4 and 5 11 Section 6 11 Section 7 I

______,..,_________._________________________,

.,_

Section 4 - Information on Each Household Members

46.
Has
Person
Income
Number

47. SNAP
Participation

48. Relation
to Head
of
Household

49. Age

SO.Sex

51. Race

52.Citizenship 53. Edu.
Status
Level

54.Emp.
a.Status

Emp.
b.Hours

55.
SNAP
Work
Reg.

56.
SNAP
E&T

57.
ABAWD
Status

58.Dependent
Care Cost

Section S - Income Identified by Household Member

59. Person
Number

Source I
60. Income Type

61. Amount

Source 2
62. 1ncome ..,ype

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63. Amount

Source 3
64. 1ncome ..,ype

65. Amount

Source 4
66. Income Type

67. Amount

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Case Information (QC Review Number: 999999)
Revision:

O - Original

Status:

New File

.____s_a_ v_e ___.l,I__E_d_it_C_h_ e _c_k_,I.I __A_p_p_r_o_v _e_.....ll.___D_ _e l_et_e __.....l ....__
l
Q_u_ __
t
i
.....

FNS380 1 FNS380-1 I
1
Sections 1 and 2 11 Sect._i_on
_ 3
_ -.I I Sections 4 and 5 11 Section 6 11 Section 7 I

____ _________________

..,_

_,

___,_

Section 6 - Reserved Coding
68. Timeliness of
Appl. Processing
(Expedited and
30 Day
Requirement)

69· QC Interview

70. Timeliness of
Recertification

71. Allotment
Test

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72.

73.

74.

75.

76.

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Case Information (QC Review Number: 999999)
O - Original

Revision:

Save
FNS 380

II

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Status:

II

Approve

II

ll
l e
t_ _
Q_ui_t __.
.____D_e_e
_.._ __

FNS 380-1

Sections 1 and 2

Section 3

Sections 4 and 5

Section 6

Section 7

Section 7 - Optional For State Use

I.
2.
3.
4.

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