Form FNS-209 STATUS OF CLAIMS AGAINST HOUSEHOLDS

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FORM APPROVED OMB NO. 0584-0069
Expiration Date XX/XXXX

U.S. DEPARTMENT OF AGRICULTURE
FOOD AND NUTRITION SERVICE

STATUS OF CLAIMS
AGAINST HOUSEHOLDS
CLAIMS
SUMMARY
3a.

A.

INTENTIONAL
PROGRAM VIOLATION
NUMBER
AMOUNT

1a. STATE NAME

2a. QUARTER COVERED
1 - FIRST
3 - THIRD
2 - SECOND 4 - FOURTH

1b. STATE CODE

2b. FISCAL YEAR

B.

INADVERTENT
HOUSEHOLD ERROR
NUMBER
AMOUNT

C.

STATE AGENCY
ADMINISTRATIVE ERROR
NUMBER
AMOUNT

BEGINNING BALANCE

b. BALANCE
ADJUSTMENTS (+) or (-)
4.
NEWLY ESTABLISHED
5.

TRANSFER (+) or (-)
(See Instructions)

6.

REFUNDS (20a + 20b)

7.

TOTAL
(3a + 3b + 4 + 5 + 6)

8.

CLOSED

9.

TERMINATED

10.
11a.

COMPROMISED
COLLECTION (18a)

b. COLLECTION ADJ.
(18b + 18c))
12. TOTAL
(See Instructions)
13. ENDING BALANCE
(7 LESS 12)
COLLECTION SUMMARY
14.
15.
16.
17.

CASH, CHECK, M.O.
SNAP BENEFITS
RECOUPMENT
OFFSET

18a. TOTAL
(14 + 15 + 16 + 17)
b. CASH ADJ.
(+) or (-)
c. NON-CASH ADJ.
(+) or (-)
19. TRANSFERS (+) or (-)
(See Instructions)
20a.
CASH REFUNDS
b.

NON-CASH REFUNDS

21. TOTAL
(18a+18b+18c+19-20a-20b)
22. RETENTION AMOUNT
(See Instructions)
23. NET CASH COLLECTION
(14 + 18b - 20a)

29. REMARKS (Attach separate sheet, if necessary)

24. TOTAL SA RETENTION
(22a + 22b)
25. LOC. ADJ. (+) or (-)
(23 - 24)
26. REIMBURSEMENTS DUE
FNS (See Instructions)

27. BILLING ADJUSTMENTS
(See Instructions)
28.TOTAL LETTER OF CREDIT ADJUSTMENTS
(25 + 26 - 27)
I certify that the above information is true and correct to the best of my knowledge.
30. DATE
31. TITLE
FORM FNS-209 (12-08)

32. SIGNATURE
Electronic Form Version Designed in Adobe 8.1 Version

No further monies or other benefits may be paid out under this program unless this report is completed and filed as required by regulation (7 C.F.R.273)

SBU

FNS-209 INSTRUCTIONS
GENERAL INSTRUCTIONS
This report shall cover the State's activities relating to recipient claims during the report
quarter and the status of claims from previous reports. Submission to the Food and Nutrition
Service (FNS) of a consolidated State level report is required. Each State agency (SA) shall
prepare an original and two copies. The original and one copy shall be submitted to the FNS
Regional office so that it will be received in that office by the 30th day following the end of
the report quarter. State agencies shall retain the second copy for audit purposes. The report
must be submitted even if no payments are collected during the quarter.
Line1a State
Enter name of State
Line 1b State Code
Enter the 2-digit code of the State.
Line 2a Quarter Covered
Enter the code (1, 2, 3, or 4) for the Federal fiscal quarter the report covers.
Line 2b Fiscal Year
Enter the last two digits of the Federal fiscal year the report covers.
Line 3a Beginning Balance
Enter the number and total value of active and suspended claims as shown on the ending
balance of the previous quarter's report in the appropriate categories of A-Intentional
Program Violation, B-Inadvertent Household Error, or C-State Agency Administrative
Error.
Line 3b Balance Adjustments
Use this line to adjust balances to reflect amendments or corrections which need to be made
to account for incorrect or changed entries in the claims summary section of a previous
quarterly report. This line shall also be used to reflect previously ter- minated or
compromised claims that arc being reactivated and to record claims that are transferred to
or from another State. See ''special instructions'' below. DO NOT use this line to reflect a
claim change from one category to another as a result of a hearing or court determination
(this type of adjustment is handled in line 5. Adjustments shall be made by using (+) and (-)
signs. For example, an SA admin- istrative error claim of $100 was incorrectly posted on a
previous report as a household error claim. The adjustment in the amount column of this
report would be reflected by showing a + $100 in column C and a - $100 in column B.
Corresponding (+) or (-) adjustments must also be reflected in the number columns for
categories B and C.
Line 4 Newly Established
Enter the number and total value of all claims established during the report quarter
(including those under the minimum amount established in Section 273.18(d)(1)(i)(A) of
the regulations) for categories A, B and C. DO NOT use this line to report the reactivation
of a previously suspended, terminated or compromised claim amount. "For the purpose of
this report, a claim is established for tracking purposes as of the date of the initial demand
letter or written notification".
Line 5 Transfers (+) or ( - )
Use this line to reflect that a claim changed from one category to another solely because of
a hearing or court determination. All other changes between categories are to be reflected in
line 3b above. The amount of the balance due on the claim is all that should be reflected in
the amount column of this line, not the amount of the original claim. Use (+) and (-) signs
as appropriate. The number column must also reflect a corresponding (+) or (-) adjustment.
See ''special instructions'' below.
Line 6 Refunds
Self-explanatory.
Line 7 Total
Self-explanatory. Be sure that (+) and (-) signs are used as appropriate.
Line 8 Closed
Enter the number of claims closed this quarter. For the purpose of this report, closed is
defined as the State agency having received payment in full, or compromised the amount
down to zero. If the amount is compromised to zero, it must also be reflected as closed in
line 10. Please note that closed on this form does not include terminations (these are
handled in line 9).
Line 9 Terminated
Enter the number and balance due of those claims which have been determined in
accordance with Section 273.18(e)(3) of the regulations to be uncollectible for categories
A, B and C.
Line 10 Compromised
Enter the number of claims compromised and the amount in accordance with Section
273.18(g)(2) and (3) by which the claim has been compromised, not the remaining balance
of a particular claim. For example: Claim Amount is $500. Household can pay $300 over
time, so the claim is compromised by $200. The amount to be reflected in line 10 is the
amount by which the claim was compromised ($200 in this example).
Line 11a Collections
Self-explanatory.
Line 11b Collection Adjustments
Self-explanatory. Be sure that (+) and ( - ) signs are used as appropriate.
Line 12 Total
For the ''number'' columns, enter the sum of lines 8 and 9. For the ''amount'' columns, enter
the sum of lines 9, 10, 11a and 11b. Be sure that (+) and (-) signs are used as appropriate.
Line 13 Ending Balance
Self-explanatory.
Line 14 Cash, Check, Moneyorder
For categories A, B and C, enter the total value of claim payments made in the form of
cash, check or moneyorder. All payments are to be recorded on the report for the quarter in
which the household actually presented the payment.

Line 15 SNAP Benefits
For categories A, B and C, enter the total value of SNAP Benefits provided by the household
as a form of payment for a claim. Such payments are to be recorded on the report for the
quarter in which the household actually presented the SNAP Benefits as payment.
Line 16 Recoupment
Enter the total value of collections made through allotment reductions. DO NOT use this
line to record collections made through offsetting restoration of lost benefits (this is shown
on line 17).
Line 17 Offset
Enter the total value of collections made by offsetting restored benefits against outstanding
claim balances. For example, a claim exists for a household in the amount of $160 but it is
also determined that the recipient is entitled to $50 in restored benefits. Offsetting the
restored benefits ($50) from the claim balance ($160) reduces the claim balance to $110.
The $50 is the offset amount to be reported in line 17. Offsets shall be reported in the
quarter in which the restored benefits are to be provided.
Line 18a Total
Self-explanatory.
Line 18b Cash Adjustments
Use this line to reflect any amendments or corrections to the collection summary of a
previous report related to cash, check, or moneyorder collections. Use ( + ) and (-) signs as
appropriate. DO NOT use this line to reflect changes that occur because a claim was
changed from one category to another due to a hearing or court determination (this type of
adjustment is handled in line 19). See ''special instructions'' below.
Line 18c Non-cash Adjustments
Use this line to reflect any amendments or corrections to the collection summary of a
previous report relative to the return of SNAP benefits, recoupment, or offsetting transactions.
Use (+) and (-) signs as appropriate. DO NOT use this line to reflect changes that occur
because a claim was changed from one category to another due to a hearing or court
determination (this type of adjustment is handled in line 19). See ''special instructions''
below.
Line 19 Transfers
Use this line to reflect claims that were contained in the collection summary of a previous
report and which are being transferred from one category to another because a hearing or
court determination. There must be a corresponding entry on line 5 of the claims summary
to reflect the transfer of the claim. Use the (+) and (-) signs as appropriate. Any other
adjustments between categories are to be reflected in line 18b or 18c as appropriate. See
"special instructions" below.
Line 20a Cash Refunds
Enter the value of cash refunds provided to households that overpaid claims.
Line 20b Non-Cash Refund
Enter the value of non-cash refunds provided to households that overpaid claims.
Line 21 Total
Self-explanatory. Be sure that (+) and (-) signs are used as appropriate.
Line 22 Retention Amount
In column A, enter 35 percent of the amount recorded on line 21, category A. In column B,
enter 20 percent of the amount recorded on line 21, column B.
Line 23 Net Cash Collections
Enter the total value of cash funds collected: add lines 14 and 18b for categories A, B and
C; then subtract line 20a for all categories. Use (+) and (-) signs as appropriate.
Line 24 Total State Agency Retention
Self-explanatory.
Line 25 LOC Adjustment
Self-explanatory, except that the entry must be reflected as a ( + ) or (-) figure. A negative
figure represents a credit to the State agency.
Line 26 Reimbursements
Due FNS Enter the total value of Title IV-D child support payments due FNS in
accordance with Section 276.2(e) of the regulations.
Line 27 Billing Adjustments
Enter the total value of collections on overissuances for which the SA has paid FNS
through the FNS-46 billings or other billings that result from investigations, audits, or gross
negligence charges, etc. DO NOT include collections on overissuances for which the State
has paid FNS through the FNS-259 billing system. This figure represents a credit to the
SA. In ''Remarks'' or on a separate sheet of paper identify which FNS-46 report or other
billing charge was involved and provide the date the billing was paid and the value of the
overissuances that were paid.
Line 28 Total LOC Adjustment
Enter the total amount which is obtained by adding the total shown in line 26 to the total
shown in line 25 (+) or ( - ) and subtracting the total in line 27. Please indicate whether the
amount is a negative or positive figure. If the amount remaining is a negative figure the
LOC will be increased by this amount to reflect a credit to the State. If the amount
remaining is a positive figure, the LOC will be reduced by this amount.
Line 29 Remarks
Attach a separate sheet to the FNS-209 if necessary.
Line 30 Date
Enter the date that the FNS-209 is signed.
Line 31 Title
Enter the title of the person who signs the FNS-209.
Line 32 Signature
The responsible Person who will certify that the information provided is correct, shall sign
the form.
Special Instructions for Lines 3b, 5, 18b, 18c and 19:
Especially for these line items, entries must be clearly identified and explained.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number of this information collection is 0584-0069. The time required to complete this collection is estimated to
average 3.0 hours per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review
the information collected.