| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | FORM IM-114, VOLUNTARY REPAYMENT AUTHORIZATION FORM AND INSTRUCTIONS FORMS MANUAL REVISION #5: IM-114, VOLUNTARY REPAYMENT AUTHORIZATION FORM AND INSTRUCTIONS |
DISCUSSION:
Form IM-114, Voluntary Repayment Authorization Form and instructions are revised. The changes to the form include:
- changed Division of Family Services to Family Support Division;
- updated the Instructions for Completion to remove the references to MOP and added EBT terminology;
- updated the authorization statement to specify the repayment for Food Stamps and/or Temporary Assistance is being removed from the individual's EBT account; and
- added the retention period.
The IM-114 form and instructions will soon be available on the Intranet. To access the PDF version and/or instructions,
- go to Family Support Division (FSD) Intranet site;
- select Food Stamps;
- under Forms, select Forms Manual from the drop-down list;
- Select Volume 2; and
- Select IM-114, for instructions.
To access the WORD version:
- go to D:\FSForms; and
- select the IM-114 form.
Use the current supply of the IM-114 until depletion. Order this form from the warehouse using normal ordering procedures.
NECESSARY ACTION:
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Review this memorandum with appropriate staff.
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Use the current supply of the IM-114 to depletion.
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Order the IM-114 (06/08)from the warehouse using normal ordering procedures.