111-3          COMPLETING THE REPORT OF CLAIM DETERMINATION FORM (GEN #95)

The Gen #95 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 #95):

Case Name: The name of the individual listed as the Primary Information Person (PI Primary Information Person ) in EIS Eligibility Information System .

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

Case Number: The EIS Eligibility Information System case number.

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

Program Type: Select the program type: Alaska Temporary Assistance, APA Adult Public Assistance , or Food Stamp 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 underissuance.

Amount of Benefit Issued: The dollar amount showing in EIS Eligibility 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.

Signatures: The caseworker completing the Report of Claim Determination prints and signs his/her name.  The supervisor signature is optional.  Refer to your  office procedures to determine whether your supervisor requires a supervisory review and/or signature.