(This Policy Bulletin Replaces PB #11-16-OPE)
The purpose of this policy bulletin is to introduce forms FIA-1004 and FIA-1004a, and announce the revision of Form W-204D. Forms FIA-1004 and FIA-1004a have been developed to assist JOS/Workers in processing and documenting CA cases that require a recoupment.
Form W-204D has been updated to reflect current Agency terminology and requirements for the recoupment procedure. Form FIA-1004 is a worksheet that will help JOS/Workers calculate the correct overpayment. Before initiating a recoupment, JOS/Workers must determine the recoupment amount by entering the following information on Form FIA-1004:
• Worker's Name (name of JOS/Worker processing the recoupment).
• Date (date worksheet is being prepared).
• Originating Center/Work Location (Center number and address).
• Case Name (as indicated in WMS).
• Case Number.
• Suffix (two-digit number, e.g. 01).
• Date of Discovery (month, date, and year the Agency became aware of the overpayment).
• Individual Matched (name of individual whose income caused the overpayment).
• Line Number (of matched individual).
• Total Offense Period (total number of CA cycles during which the household received an overpayment).
• In column A, the cycle dates of the offense period during which the household received an overpayment.
• In column B, the semimonthly amount of CA grant received by the household during the offense period.
• In column C, the number of cycles within the offense period.
• In column D, the amount of income available to the household during the offense period, minus applicable income disregards. This amount should be determined using the Determining Available Income section on page 2 of the form.
• In column E, the new grant amount with income applied.
• In column F, the total new grant amount, with income applied, during the entire offense period.
• In column G, the total grant amount actually received during the offense period.
• In column H, the overpayment amount to be recouped.
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