Appendix B: Completion of the OIG 173

Section I

CLAIM INFORMATION – COMPLETE ALL REIMBURSEMENT REFERRALS

ITEM 1

PAYMENT NAME – Enter the last name, first name, and middle initial of the payment name.

ITEM 2

CO – Enter the two digit county code.

ITEM 3

RECORD NO – Enter the seven digit record number. If necessary, use zeros in front of a number to increase the digits to seven.

ITEM 4

CAT – Enter the letter(s) indicating the category of assistance.

ITEM 5

GG – Enter the budget group number if there is more than one budget group in the case with the same category.

ITEM 6

DIST – Enter the letter or number of the district office, if applicable.

ITEM 7

CLAIM NAME – Enter the last name, first name, and middle initial of the person who owns, who received, or who is to receive the delayed personal property if different from Item 1. If the same as Item 1, enter SAME. If there is more than one claim name, enter the additional claim name(s) in Section V.

ITEM 8

SOCIAL SECURITY NUMBER – Enter the nine-digit social security number of the claim name. Include the social security numbers for additional claim names in Section V, if known. Also, if the benefit is received by a minor, enter the minor’s social security number in Section V.

ITEM 9

LINE NUMBER(S) FOR WHOM CLAIM NAME IS LIABLE – Enter the line number(s) for whom the claim name is legally responsible, including the claim name. If reimbursement applies to the entire household, enter ALL.

ITEM 10

RE CODE – Enter the two-digit reimbursement code from the back of the OIG 173-S which describes the personal property subject to reimbursement. If Code 09, MISCELLANEOUS, is used, explain in Section V.

ITEM 11

REASON FOR REFERRAL – Enter the two-digit code from the back of the OIG 173-S which best describes the reason for the referral. If 03 is used, explain the reason in Section V.

ITEM 12

REFERRAL STATUS – Check the appropriate box. If the follow-up box is checked, enter the month, day, and year of the initial OIG 173-S.

ITEM 13

REIMBURSEMENT FORM(S) ATTACHED – Check the appropriate box(es).

SECTION II

PERSONAL INJURY INFORMATION – COMPLETE FOR REIMBURSEMENT CODES 04 AND 08

ITEM 14

TYPE OF INJURY – Describe the injury such as auto accident, medical malpractice, or fall.

ITEM 15

DATE OF INCIDENT – Self-explanatory.

ITEM 16

INSURANCE COVERAGE – Check the appropriate box to indicate whether an insurance company may pay for the personal injury. If yes, complete Item(s) 21 and/or 22.

ITEM 17

NAME OF INJURED PERSON – Self-explanatory. If there is more than one name, enter additional names in Section V.

ITEM 18

LINE NO – Enter the line number of the injured person(s).

ITEM 19

LEGAL ACTION – Check the appropriate box to indicate whether an attorney is involved. If yes, complete Item(s) 23 and/or 24.

ITEM 20

NAME/ADDRESS OF LIABLE PARTY – Enter the name and address of the person or party responsible for the personal injury.

ITEM 21

NAME/ADDRESS/POLICY INFORMATION OF LIABLE PARTY’S INSURANCE CO – Enter the insurance company name and address of the person or party responsible for the personal injury. Also, enter the policy number, claim number, and insurance company’s telephone number.

ITEM 22

NAME/ADDRESS/POLICY INFORMATION OF INJURED PERSON’S INSURANCE CO – Enter name and address of injured person’s insurance company. Also, enter the policy number, claim number, and insurance company’s telephone number.

ITEM 23-24

Self-explanatory.

SECTION III

ESTATE INFORMATION – COMPLETE FOR REIMBURSEMENT CODE 06

ITEM 25

NAME OF DECEDENT – Enter the name of the deceased person from whom the client will inherit personal property.

ITEM 26-29

Self-explanatory.

SECTION IV

RECEIPT OF PERSONAL PROPERTY

ITEM 30

DATE NORMALLY DUE – For delayed benefits, enter the date the client should have received the benefit. For initial federal benefits, enter the date the client became eligible for the retroactive benefit (date of entitlement). For personal injury or inheritance, enter N/A.

ITEM 31

DATE RECEIVED – Enter the month, day, and year the benefit, award, income, or inheritance was received by the client.

ITEM 32

AMOUNT RECEIVED BY CLIENT – Enter the net amount of the benefit, award, income, or inheritance received by the client. This figure is the amount after subtracting expenses the client paid to be eligible for or to receive the delayed personal property.

SECTION V

COMMENTS

ITEM 33

EXPLANATION/COMMENTS/OTHER INFORMATION – Enter any additional information which will help protect or collect the claim. All additional information must be identified by the related Item number. If a payment is collected at the CAO, enter the serial number of the PA/CS 175-M.

SECTION VI

CAO SIGNATURES – COMPLETE FOR ALL REIMBURSEMENT REFERRALS

ITEM 34

PREPARED BY – Complete by the Income Maintenance Caseworker who prepared the referral.

ITEM 35

APPROVED BY – Complete by the Executive Director or designee.