Number of Pages
Enter the number of pages included in the notice. For example, 1 of 2, 2 of 2, etc.
Date of Notice
Enter the date the form is sent to the client.
Case ID Number
Enter the current category, office, and basic number.
Caseload Number
Enter the caseload number of the caseworker filing the report.
Client Name and Address
Enter the client's name and address as shown on HFS 552, Items 8, 9, and 10.
Original or Additional Overpayment
Check the box for original or additional overpayment and the amount of the overpayment. Enter the amount using whole dollars. If the overpayment is an additional overpayment, enter the old overpayment period and the old and revised
overpayment amounts.
Overpayment Reason
Enter the reason for the overpayment using clear and simple language. Do not use abbreviations 
such as ICL or form numbers. The reason message must be specific; For example, "...due to your unreported wages from the ABC Co."
For excess asset overpayments, use the following wording:
This overpayment occurred because of excess assets. The overpayment amount is the lesser of $(cash benefit amount) or $(excess asset amount).
Calculation of Overpayments
Always use whole dollar amounts.
Cash
| Cash Received |
Enter the cash amount received by the client. If the cash amount was reduced by a monthly recoupment, add the monthly recoupment amount to the cash benefit received. Enter cash benefit amounts even if the overpayment is due to excess
assets. |
| Correct Cash Amount |
Enter the cash amount that the client was eligible to receive. |
| Overpayment |
Enter the difference between the cash received and the correct cash amount. |
| Support Payments |
For months of total ineligibility, subtract any child support payments kept by HFS minus the pass through payment. |
| Adjusted Overpayment |
Overpayment amount minus support payments. |
| Months |
Enter the period of overpayment. For changes in cash amounts, complete a separate calculation for each differing grant. |
| Number of Months |
Enter the number of months in the overpayment period. |
| Net Overpayment |
Enter the result of the number of months times monthly adjusted overpayment amount. |
| Total Cash Overpayment |
Enter the total of the net overpayment amounts. |
Food Stamps
| Amount Food Stamps Received |
Enter the monthly benefit amount received by the FS unit. If the allotment was reduced by a monthly recoupment, add the monthly recoupment amount to the allotment received. |
| Correct Amount of Food Stamps |
Enter the coupon allotment that the FS unit was eligible to receive. |
| Overpayment |
Enter the difference between the allotment received and the correct allotment. |
| Months |
Enter the period of overpayment. For changes in allotment amounts, complete a separate calculation for each differing allotment. |
| Number of Months |
Enter the number of months in the overpayment period. |
| Overpayment |
Enter the results of the number of months times the monthly overpayment amount. |
| Total Food Stamp Overpayment |
Enter the total of the overpayment amounts. |
Total Overpayment Amount
Enter the total combined cash and FS overpayment amounts.
Form Completed By
The person completing the form enters their name.
