Form ACF-403 Improper Payment DCI - ACF-403 Record Review Worksheet:

OMB Control Number: 0970-0323
Expiration Date: xx/xx/20xx

RECORD REVIEW WORKSHEET (ACF-403)
CHILD ID#

STATE:

COUNTY:

SAMPLE MONTH/YEAR:

REVIEW DATE:

SECTION I. STATE CHILD CARE PROGRAM FORMS
ELEMENTS OF ELIGIBILITY & PAYMENT
DETERMINATION (1)
100 APPLICATION/REDETERMINATION FORMS

ANALYSIS OF CASE RECORD (2)

FINDINGS (3)
N/A

N/A

RESULTS (4)
100 RESULTS

Determine whether required eligibility forms met all state and
federal policies in effect during the sample month. Examples
include (1) application form; (2) child care agreement; (3)
declaration of family assets, as determined by a family
member; (4) voucher or certificate, as applicable; and (5)
forms related to presumptive eligibility, as applicable.

1.
2.

No Error / Error
Missing/Insufficient Documentation
(If “Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

SECTION II. PRIORITY GROUP PLACEMENT
ELEMENTS OF ELIGIBILITY & PAYMENT
DETERMINATION (1)
200 PRIORITY GROUP PLACEMENT
Determine whether client met criteria of any state-designated
priority group, e.g., special needs or low income.

ANALYSIS OF CASE RECORD (2)
N/A

FINDINGS (3)
N/A

RESULTS (4)
200 RESULTS

1.
2.

No Error / Error
Missing/Insufficient Documentation (If
“Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

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SECTION III. GENERAL PROGRAM REQUIREMENTS
ELEMENTS OF ELIGIBILITY & PAYMENT
DETERMINATION (1)
300 QUALIFYING HEAD OF HOUSEHOLD

ANALYSIS OF CASE RECORD (2)
N/A

FINDINGS (3)
N/A

Determine whether client met parent definition (parent means
a parent by blood, marriage, or adoption and also means a
legal guardian, or other person standing in loco parentis), e.g.,
(1) parent, (2) step-parent, (3) legal guardian, (4) needy
caretaker relative, or (5) spouse of same.
310 RESIDENCY

N/A

N/A

N/A

N/A

Determine if the child met eligibility criteria including (1) age
(younger than 13 years, or younger than 19 years and
physically or mentally incapable of caring for himself or
herself or under court supervision), (2) citizenship/qualified
alien status as set forth in federal policy, and (3) other
eligibility requirements as defined in the state plan.

N/A

Missing/Insufficient Documentation
(If “Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

No Error / Error
Missing/Insufficient Documentation (If
“Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

320 RESULTS

1.
2.

N/A

No Error / Error

310 RESULTS

1.
2.

Determine whether the child’s parent or parents were
working, attending a job training or educational program
(including a job search if applicable), or if the parent or
parents had a child receiving or needing to receive protective
services under the state’s definition.
330 QUALIFYING CHILD

300 RESULTS

1.
2.

Determine whether client was a resident according to state
policy.

320 PARENTAL WORK/TRAINING STATUS

RESULTS (4)

No Error / Error
Missing/Insufficient Documentation
(If “Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

330 RESULTS

1.
2.

No Error / Error
Missing/Insufficient Documentation (If
“Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

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ELEMENTS OF ELIGIBILITY & PAYMENT
DETERMINATION (1)
340 QUALIFYING CARE

ANALYSIS OF CASE RECORD (2)
N/A

FINDINGS (3)
N/A

Determine whether the number of hours, type of care, and
provider payment rate authorized for the sample month were
correct based on state policy.

350 QUALIFYING PROVIDER ARRANGEMENT
Determine whether services were provided by a center-based
child care provider, a family child care provider, or an inhome child care provider, and that the provider met all
applicable requirements, including health and safety
requirements.

RESULTS (4)
340 RESULTS

1.
2.

N/A

N/A

No Error / Error
Missing/Insufficient Documentation (If
“Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

350 RESULTS

1.
2.

No Error / Error
Missing/Insufficient Documentation (If
“Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

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SECTION IV. FINANCIAL REQUIREMENTS AND PAYMENT
ELEMENTS OF ELIGIBILITY & PAYMENT
DETERMINATION (1)

400 FINANCIAL REQUIREMENTS

ANALYSIS OF CASE RECORD (2)
N/A

FINDINGS (3)
N/A

Specify time period (e.g., based on 4 weeks prior to
application) and all income to be considered based on state
policies and definitions (e.g., head of household
employment). Determine:



whether income verification and calculations for
household members were correct.



whether household income met state requirements (e.g.,
family gross income must be within X percent of state’s
median income).



whether the copayment (if any) was correctly applied.

410 PAYMENT
Identify the eligibility worker’s subsidy amount for the
sample month and compare it to the reviewer’s subsidy
amount for the sample month. If the amounts are the same
there is no improper payment error.

RESULTS (4)

400 RESULTS
1.
2.

N/A

N/A

No Error / Error
Missing/Insufficient Documentation (If
“Y” is coded, answer 2A)
2A. Potential Improper Payment Error
(If “Y” is coded, use the MID Table)

410 RESULTS
1.
2.

No Error / Error
Missing/Insufficient Documentation

If the amounts are different, compare the reviewer’s subsidy
amount to the sample month payment amount.
If the sample month payment was a full payment and was:
o greater than the reviewer’s subsidy amount, the difference
may be an overpayment (improper payment).
o less than the reviewer’s subsidy amount, the difference
may be an underpayment (improper payment).

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Record Review Worksheet Missing and Insufficient Documentation Table (MID Table)
Child ID:

1
2
Element Describe
documentation
that was
missing or
insufficient.

3
Dollar
amount of
potential
improper
payment.

4
Is there an
additional
inquiry that
can be
made to
mitigate the
potential
improper
payment
error?
0=No
1=Yes

5
If No,
describe
why not.
(Note: After
responding, go
to Element 500
if there are no
other Elements
requiring the
MID Table.)

6
If Yes,
describe the
additional
inquiry.

7
Was the
improper
payment
mitigated
using the
additional
inquiry?
0=No
1=Yes

8
Enter dollar
amount that
was
mitigated.

9
Describe how
the state
determined
whether or not
the potential
improper
payment could
be mitigated.
(Note: Please respond
to this whether the
potential improper
payment was mitigated
or not mitigated.)

100
200
300
310
320
330
340
350
400
Total

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SECTION V. CASE SUMMARY
FINDINGS (1)

500 CASE SUMMARY

RESULTS (2)

500 RESULTS
1.
2.

3.
4.
5.

No Error / Error
Missing/Insufficient Documentation
2A: Number of MID potential improper payment errors identified
2B: Total amount of MID potential improper payment errors
2C: Number of times an additional inquiry was used
2D: Number of times the additional inquiry mitigated the potential improper
payment error
2E: Total amount of improper payments mitigated
Overpayment/Underpayment
Total Amount of Improper Payment
Total Payment Amount for Sample Month

The coding for the Results Column for Elements 100 – 400 is as follows: 1: "0" = no error, "1" = error; 2: "Y" = error due to missing or insufficient
documentation, "N" = error not due to missing or insufficient documentation, "NA" = no error; 2A (only coded if 2 is coded as “Y”): “Y” = MID potential
improper payment error, “N” = not a MID potential improper payment error.
The coding for the Results Column for Elements 410 is as follows: 1: "0" = no error, "1" = error; 2: "Y" = error due to missing or insufficient documentation, "N"
= error not due to missing or insufficient documentation, "NA" = no error.
The coding for the Results Column for Element 500 is as follows: 1: "0" = no error, "1" = error; 2: "Y" = error due to missing or insufficient documentation,
"N" = error not due to missing or insufficient documentation, "NA" = no error; 2A: Number of times the MID Worksheet was used because a MID potential
improper payment error was identified; 2B: Total dollar amount of MID potential improper payment errors (total of column 3 on the MID Table); 2C: Number of
times an additional inquiry was used (total of column 4 on the MID Worksheet); 2D: Number of times the additional inquiry mitigated a MID potential improper
payment error (total of column 7 on the MID Table); 2E: Total dollar amount of improper payments mitigated (total of column 8 of the MID Worksheet); 3: “U”
= Underpayment, “O” = Overpayment, "NA" = no improper payment; 4: Total dollar amount of improper payment; 5: Total Payment Amount for Sample Month.
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to gather
data from states once every three years about the errors occurring in the administration of CCDF grant funds. Public reporting burden for this collection of
information is estimated to average 3.0 hours per response (case record reviews) and 63 hours per response (customization of template), including the time for
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (45
CFR Part 98, Subpart K). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the
requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0323 and the expiration
date is xx/xx/20xx. If you have any comments on this collection of information, please contact ACF Office of Child Care.

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