Complete a handwritten 
DHS 2404 as follows. See IPACS III Manual Chapter 2300 for ACM processing instructions.
CASE IDENTIFICATION
Complete for all referrals.
Referral Date
Enter the date (MM/DD/YY) that the form is processed for review. The referral date is the day the report is processed through ACM.
ARS Account Number
If appropriate, enter the account number displayed at the top of the ARS Account Level Screen (PF/F10).
1-3 - Referral Type
- Show if the overpayment is cash, SNAP, or both by checking the correct box:
- 1 - Grant
- 2 - SNAP
- 3 - Both
4 - Central Office Use Only
Leave blank.
5 - Responsibility Code
If the referral is completed:
- by the Family Community Resource Center - enter the FCRC number;
- by Program Support Services - enter "PSS";
- by the Bureau of Investigations - enter "BOI"; or
- for transferred cases - enter the number for the FCRC that determined the overpayment.
6 - Crossmatch Code
Enter the appropriate PAL code. For special crossmatches, enter the Match Code shown on the Data Exchange Match Sheet or the Special Review Guidelines. These entries are always 3-digit codes.
7 - Caseload Number
Enter the caseload number of the caseworker completing this referral.
8 - Status
Circle "active" if aid will continue. If aid is ending or has already ended, circle "canceled".
9 - As of
For active cases, enter the current month and year. For canceled cases, enter the effective month and year of cancellation.
10 - Total Combined Grant and SNAP Overpayment
Enter the total cash and SNAP overpayment amount and the total period of overpayment for this referral. Drop cents when entering the overpayment amount.
11 - Total Grant Overpayment
Enter the total cash overpayment amount and the period of overpayment for this referral. Drop cents when entering the asset limit.
12 - Grant Overpayment, Excess Assets
Indicate if the cash overpayment is because of excess assets. Enter the asset amount that exceeds the asset limit.
13 - Total SNAP Overpayment
Enter the total SNAP overpayment amount and the period of overpayment for this referral. Drop cents when entering the amounts.
14 - Quality Control
Indicate if the referral is the result of a Quality Control Review.
15 - Case Name
Enter the case name.
NOTE: For cases that have a Representative Payee (RPY), Temporary Payee (TEMP), or Protective Payee, enter information that applies to the caretaker relative in Items 15, 16, 17, 18, 19, 24, 25, and 26. In Item 15A, enter the payee indicator. For cases that had an RPY during the period of the overpayment, enter the RPY's SSN in Item 21 and date of birth in Item 26. If the SSN is unknown, enter all zeroes. If the date of birth is unknown enter 01/01/1901.
16 - Address
Enter the case address.
17 - City
Enter the name of the city.
18 - State
Enter the name of the state.
19 - Zip
Enter the zip code.
20 - Telephone Number
The phone number is used in contacting the overpaid family and must be completed (including area code) on all FCRC referrals. Enter zeroes if the family does not have a phone.
21 - Social Security Number (SSN)
Enter the payee's SSN on all FCRC referrals. For ineligible or undocumented noncitizens, enter all zeroes. For RPY cases, enter the SSN of the RPY, if known. If not known, enter all zeroes.
22 - Current Case ID Number
Enter the current category, office number, group, and basic number. For units that have received aid before under a different case number(s), complete the identifying information for the previous case(s). For transferred cases, enter the case number for the sending office.
23 - Recipient ID Number
Enter the payee's RIN taken from Item 60 of 552. For RPYs, ineligible or undocumented noncitizens, leave this item blank.
24 - Sex
Enter the sex of the payee:
1 - Male
2 - Female
25 - Race
Enter the number code taken from Item 13 or the alpha codes taken from Item 80 295 RCE/ETH code of 552.
26 - Birth date
Enter the birth date for the payee taken from Item 61 of 552. For ineligible or undocumented noncitizens, enter 01/01/1900. For RPY cases, enter the birth date if known. If unknown, enter 01/01/1901.
27 - Second Adult Name
If appropriate, enter the name, birth date, SSN, sex, and race of the 2nd responsible adult.
OVERPAYMENT TYPES AND REASONS
Indicate the type of referral:
| Cash |
SNAP |
| Client Error, Agency Error, or Both |
Suspected Intentional Client Error, Inadvertent Client Error, or Agency Error |
NOTE: If the period of SNAP overpayment includes months of client error and agency error, do a separate DHS 2404 for each type of error.
For SNAP, BOC reviews the circumstances surrounding the overpayment and decides if the designation is correct. If the designation is incorrect, BOC will call the FCRC with the change.
Enter the date the overpayment was identified by the FCRC.
In the space provided, tell how the overpayment happened. Include in the description any dates of client contact and a list of supporting documentation.
SNAP CLIENT ERROR REFERRALS
For all SNAP client errors, include the name, birth date, SSN, and sex of the person who caused the overpayment and how the overpayment was discovered.
If the overpayment is because of employment, enter the name and address of the employer in the space provided. In the space titled "Monthly Earned Income", enter the amount of current monthly income. If employment is ended, enter the last monthly amount earned. Enter this information for both government and non-government employees.
Also in this section, enter the date of the last application, monthly reports, or SNAP REDE before the first month of overpayment; and the date of any applications, monthly reports, or SNAP REDEs completed during the period of overpayment.
If the person who caused the overpayment was previously convicted of welfare fraud or disqualified due to an administrative action, check the box.
For duplicate assistance cases, enter information on the duplicate case names, case ID numbers, and if appropriate other state of residence. For cases with multiple SSNs, enter the other SSNs used by the client.
If there was a previous administrative action, list the date and type.
Enter the name and title of the person completing the form. Include the date. The supervisor and FRC also sign and date the form after their review.
