IM-123 09/14/99 INTERIM CHANGE RECORDING FORM-MANUAL REVISION
| SUBJECT: |
| INTERIM CHANGE RECORDING FORM
FORMS MANUAL REVISION #35 IM-145A AND INSTRUCTIONS |
| DISCUSSION: |
Because there are a variety of change
recording forms currently in use statewide to record changes reported by
the participant by telephone or in person, the Vision Team suggested a
standardized form. Based on this suggestion, the IM-145A was developed
to provide a method to:
An initial supply of the IM-145A is being sent to each county office. Upon receipt of the initial supply of the IM-145A, it may be necessary to order additional copies to ensure that sufficient quantities are available. Order additional supplies of the IM-145A through normal channels. |
| NECESSARY ACTION: |
Distribution #3 |
| IM-145A Instructions, Page 1
INTERIM CHANGE RECORDING FORM PURPOSE: To provide a method for recording changes reported by a participant or on behalf of a participant and tracking the action taken on the reported change. Space is provided on the form to record information about the action taken on the reported change and to record changes in the food stamp allotment. NUMBER OF COPIES AND DISPOSITION: This form is printed on three part NCR paper. Give the original to the caseworker managing the caseload that includes the participant. File the original in the case record. Give one carbon to the IM supervisor. Use of the third carbon is optional by clerical to track the action taken on the reported change. INSTRUCTIONS FOR COMPLETION: This form may be completed in ink or typed. Case Name: Enter the participant's name as it appears in the FSU5/IMU5 system. DCN: Enter the participant's DCN. To: Enter the name of the caseworker for whom the reported change is intended. From: Enter the name of the individual taking the information on the reported change. Date of Contact: Enter the date the information was reported. Time: Enter the time the information was reported. Participant's Phone Number: Enter the participant's phone number or message number. SSN: Enter the participant's Social Security Number (SSN). Birthdate: Enter the participant's birthdate. Information Reported: Record the information reported. Rent amount: If the reported change is due to a move, record the amount of rent for the new residence. August 1999 IM 145A Instructions, Page 2 Primary heating/cooling expense: If the reported change is due to a move, indicate with Y or N if the household is responsible for a primary heating/cooling expense. Telephone: If the reported change is due to a move, indicate with Y or N if the household is responsible for a telephone expense. Utility expenses other than primary heating/cooling: If the reported change is due to a move and the household is not responsible for a primary heating/cooling expense, indicate with Y or N if the household is responsible for utility expenses other than primary heating/cooling. This would include gas or electricity (used for cooking, heating water, etc.), water, sewer, trash, etc. Do not include cable television charges. Reported By: Enter the name of the person reporting the information (if reported by someone other than the participant). Phone Number: Enter the phone number of the person reporting the information (if reported by someone other than the participant). Date IM-31A Sent: Enter the date the IM-31A requesting information was sent to the participant. Date IM 12A Sent to the Household: Enter the date the IM-12A was sent to the household for the employed individual's signature. Date IM-12A Sent to Employer: Enter the date the signed IM-12A was sent to the employer. Additional Recording for Adjustment: Record the action taken on the reported change and information regarding the adjustment in the food stamp allotment. If no adjustment was necessary, record the reason. Supplemental Benefit Amount & Months: Record supplemental,
adjusted, or restored benefits and the month(s) for which the benefits
were issued.
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