Form Soc 330 - In-Home Supportive Services - Overpayment Collection Transaction

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES
OVERPAYMENT COLLECTION
TRANSACTION
1. RECIPIENT
2. PROVIDER NAME
3. RECIPIENT NUMBER
4. PROVIDER NUMBER
5. SEQ
6. TYPE
7. STATUS
8. START WITHHOLD
9. STOP WITHHOLD
10. ORIGINAL AMOUNT
11. DEDUCT AMOUNT
12. APPLIED AMOUNT
A
R
P
A
H
C
13. WARRANT NUMBER
14. FROM DATE
15. TO DATE
16. WITHHOLD
17. F.I.C.A.
18. S.D.I.
19. SHARE/COST
03
10
11
13
20. REASON CODES - NOA
21. COUNTY USE
22. REFERENCE
1. RECIPIENT
2. PROVIDER NAME
3. RECIPIENT NUMBER
4. PROVIDER NUMBER
5. SEQ
10. ORIGINAL AMOUNT
12. APPLIED AMOUNT
6. TYPE
7. STATUS
8. START WITHHOLD
9. STOP WITHHOLD
11. DEDUCT AMOUNT
A
R
P
A
H
C
13. WARRANT NUMBER
14. FROM DATE
15. TO DATE
16. WITHHOLD
17. F.I.C.A.
18. S.D.I.
19. SHARE/COST
03
10
11
13
20. REASON CODES - NOA
21. COUNTY USE
22. REFERENCE
COUNTY VALIDATION
23. AUTHORIZATION
DATE
REMARKS
24. VALIDATION
DATE
REMARKS
SOC 330 (3/01)

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