1 - Referral Date
Enter the date (MM,DD,YY) of the referral.
2 - Case Originally Referred On
Enter the date the FRC signed the original HFS 2404.
Type of Original Referral -Check the appropriate box to indicate if the originally established claim was cash, food stamps, or both.
Current Status of Case -Check the appropriate box to show if the case is currently active or canceled.
3 - Account Number
Enter the account number shown on the ARS Account Level Screen PF/F10.
4 - Responsibility Code
If HFS 2404C is completed by:
- the FCRC - enter the FCRC number;
- Program Support Services - enter "PSS"; or
- Bureau of Investigations - enter "BOI".
5 - Crossmatch Code
If HFS 2404C is in response to an ICL code, a change identified through central budgeting of SSA/SSI, or a special crossmatch through the FRC, enter the appropriate ICL code, BDX, SDX, or the 3-digit Match Code shown on the Data
Exchange match sheet or the Special Review Guidelines. These entries are always 3- digit codes. Enter ICL Code C as "C--" or ICL Code U as "U--".
6 - Caseload Number
Enter the caseload number of the caseworker completing the referral.
7 - Payee
Check "Yes" if there is a payee, such as RPY, TEMP, PPP, etc.
8 - Case Name
Enter the case name. If the case is an RPY case, no entry is required in Items 14, 16, or 19.
9 - Address
Enter the case address.
10 - City
Enter the name of the city.
11 - State
Enter the 2-letter abbreviation of the state.
12 - Zip
Enter the zip code.
13 - Telephone
The phone number is used to contact the overpaid client and must be completed (including area code) on all FCRC referrals. If the client does not have a phone enter zeroes.
14 - Social Security Number
Except for RPY cases, enter the payee's SSN on all FCRC initiated referrals.
15 - Case ID Number
Enter the category, office number, group, and basic number.
16 - Recipient ID Number
Except for RPY cases, enter the payee's RIN taken from Item 60 of HFS 552.
17 - Sex
Enter F (Female) or M (Male) for the payee.
18 - Race
Enter the number code taken from Item 13 or the alpha codes taken from Item 80 295 RCE/ETH code of HFS 552.
19 - Birth date
Except for RPY cases, enter the payee's birth date from Item 61 of HFS 552.
20 - Food Stamp IPV Referrals
Check this box if the 2404C is being submitted to revise the FS overpayment amount because the 20% earned income deduction is not allowed as a result of a Food Stamp IPV decision.
CHANGE OF INFORMATION
| Claim Number on ARS |
Enter the claim number from the upper center of the Claim Level Screen on ARS (PF/F10). Check the appropriate box to indicate if the claim is for cash or FS. If the original HFS 2404 has not yet been posted to ARS, enter "Not Yet on ARS". |
| Period of Overpayment |
For each claim identified, enter the previously reported overpayment period and the revised overpayment period in the space provided. Enter inclusive periods in both columns. |
| Overpayment Amount |
Enter the previously reported overpayment amount under "Information Currently in ARS" and the revised overpayment amount under "Revised Information" in the space provided. Enter all amounts in whole dollars. |
| Amount Collected to Date |
Enter the current amount collected under "Information Currently on ARS" and the revised amount collected under "Revised Information" in the spaces provided. |
NOTE: Attach HFS 2404X to HFS 2404C. Make sure the months on HFS 2404X include all the months included in the revised overpayment on HFS 2404C.
REASON FOR CHANGE
This section identifies the various reasons for adjusting the overpayment amount and/or the period of overpayment. Indicate the box that supports the reason for the change. If none of the reasons apply, check the box "Other" and explain the reason for
the change. If the overpayment amount is being reduced to zero, provide a clear explanation of why the overpayment does not exist.
| Completed by |
The person who completes the form enters their name, title, and date the form is completed. |
| Supervisor |
The supervisor who approves the form enters their name, title, and date of approval. |
| FRC |
The FRC enters their name and the date of approval. |
| Forwarding Instructions |
Send the original to the Bureau of Collections, Field Recovery Unit, Springfield. Keep one copy in the case record. |
