Special Assistance SA3410f3

Figure 3 - OVERPAYMENT CALCULATION

Client Name:

Investigator:

DSS Case Number:

Date:

Reason for Overpayment:

Amount of IV-D Obligation:

Effective Date:

$30.00 & 1/3 Disregard:

$30 Disregard:

I

II

III

PAYMENT RECEIVED

During Overpayment Period

ELIGIBILE PAYMENT

During Overpayment Period

OVERPAYMENT

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Col. 6

Col. 2

Col. 6

Adjusted Support Obligation

OVER-PAYMENT

Month/ Year

Payment Received

Payment Standard

Net Monthly Income

Deficit

Eligible Payment

Payment Received

Eligible Payment

TOTAL:

For questions or clarification on any of the policy contained in these manuals, please contact your local county office.


Client Name:		Investigator:
DSS Case Number:		Date:
Reason for Overpayment:
Amount of IV-D Obligation:		Effective Date:
$30.00 & 1/3 Disregard:		$30 Disregard:


I		II				III
PAYMENT RECEIVED During Overpayment Period		ELIGIBILE PAYMENT During Overpayment Period				OVERPAYMENT
Col. 1	Col. 2	Col. 3	Col. 4	Col. 5	Col. 6	Col. 2	Col. 6	Adjusted Support Obligation	OVER-PAYMENT
Month/ Year	Payment Received	Payment Standard	Net Monthly Income	Deficit	Eligible Payment	Payment Received	Eligible Payment	Adjusted Support Obligation	OVER-PAYMENT