Form Dss-8555 - First Month Of Overissuance Determination Semi-Annual Reporting Cases
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1Food and Nutrition Services
First month of overissuance determination
Semi-Annual Reporting Cases
Casehead Name _________________________________ EPICS Referral Number ______________________
Completed by __________________________ Date _________________ Co. Case # ____________________
A. Did the applicant withhold information or provide false information at application? ________
1.
If no, continue to B.
2.
If yes, the first month of overissuance is the first month of the certification period.
B. Did the recipient withhold information or provide false information at recertification? _______
1.
If no, continue to C for Semi-Annual Reporting Cases.
2.
If yes, the first month of overissuance is the first month of the new certification period following
the review in which the recipient withheld or provided false information. Continue to C and D if a
change occurred during a certification period and the recipient failed to report the change timely.
C. Did the recipient fail to disclose the household’s total income exceeded 130% of the Federal Poverty
Limit (FPL)? ______
1.
If no, STOP. See note below.
2.
If yes, was the increased income due to a new household member who was
determined to be a required FNS unit member?
_________
3.
If no, STOP. Go to section D.
4.
If yes, when was the recipient informed of the reporting rules effective 2/1/2007?
_________
5.
When did the household’s income exceed 130% of the FPL?
_________
If the date in C4 is more recent than the date in C5, the recipient was not required
to report the change because he/she had not been informed of the new reporting rules.
If the date in C5 is more recent than the date in C4, continue to section D.
D. In what month/year did the total household income exceed 130% of the FPL?
_________
th
1. What is the 10
day of the month following the answer in D above?
_________
(Required date to report change)
2. Add 10 calendar days to allow the IMC to react to the change.
_________
(Allow even if IMC could have reacted sooner)
3. Add 10 working days for the Notice of Adverse Action to expire.
_________
4. What is the month following the date the NOAA expires?
_________
This is the first month of overissuance.
Note: This information applies to IHE and suspected IPV claims only. The first month of overissuance
for Agency Error Claims is always the first month the change would have been effective had the
agency acted timely and according to policy. Use this form in conjunction with policy in sections
815 and 820.
DSS-8555 (09/09)
Food and Nutrition Services
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