111-3          COMPLETING THE REPORT OF CLAIM DETERMINATION FORM (GEN 95Report of Claim Determination)

The GEN 95Report of Claim Determination can be completed online from e-Forms on the DPAweb. Losses for more than one program cannot be combined. Two programs can be recorded on one form (front and back), however, each month for each program must be separately recorded.

Follow these procedures for completing the Report of Claim Determination (GEN 95Report of Claim Determination):

Case Name: The name of the individual listed as the Primary Information Person (PIPrimary Information Person) in EISEligibility Information System.

Date: The date the caseworker completes the Report of Claim Determination form.

Case Number: The EISEligibility Information System case number.

District Office: The DPADivision of Public Assistance office responsible for the case.

Program Type: Select the program type: Alaska Temporary Assistance, APAAdult Public Assistance, Senior Benefits, or SNAPSupplemental Nutrition Assistance Program.

Benefit Month: List each benefit month in which the overpayment or underpayment occurred.

Error Cause: Identify Client or Agency as the cause of each overpayment or underpayment.

Amount of Benefit Issued: The dollar amount showing in EISEligibility Information System or on the manual budget as the issuance for the month.

Amount of Benefit Entitled to: The dollar amount the benefit should have been.

Overpayment or Underpayment Amount: The overpayment or underpayment amount (the difference between what was issued and what should have been issued).

Explain how and why the overpayment occurred: Be clear and concise. Include all names, benefit months and dates, resources, income, and deduction amounts and any other relevant information pertaining to the overpayment or underpayment.

Manual Section: List the program manual section(s) that support the reason for recoupment below the explanation. For example: "SNAP MS 604 supports the action taken."

Signatures: The caseworker completing the Report of Claim Determination must print and sign his/her name. A signature of supervisor is also required. Prior to submitting the form to the Claims Specialist, a supervisor or a lead worker must sign the form and enter the date the case was reviewed.