Appendix B: The Prepopulated Semiannual Reporting Form

The SAR form (PA 564) is pre-populated with information the recipient must review. The chart below describes:

NOTE:  It is very important to keep current employment, income, and resource information on eCIS at all times. If incorrect information on eCIS is prepopulated on the SAR forms, the client may receive a form listing income and resources that are no longer valid. Current information may not be listed due to limited space.

Question

Prepopulated information

Found on CIS screen

Found in eCIS

1. These are the household members you last reported to be living in your household.

Line Number
First Name
M.I.
Last Name
Appellation
Birth Date

CQBMEM

Demographics

2. These are the household members you last reported to be working and where they worked.

Line Number
First Name
Employer
Date Employment Began

CQWAGE

Income-Employment/Wages

3. Provide proof of all work income any household member received in the month of:

Reporting Month

Based on SAR date

Based on SAR date

4. These are the household members you last reported to have income from a source other than work or public assistance.

Line Number
First Name
Type of Income
Amount of last reported unearned income

CQUNRD

Income-Unearned

6. This is the last reported amount of child support paid for children outside the household.

Total amount of support last reported paid

CQSSPT

Income-Unearned

 

7. This is the information you last reported about child care or for care of a sick or disabled person.

Line Number
Provider of care
Person paid for
Total amount last reported

CQDEPT

Expenses-Dependent Care

8. These are the household members you last reported to have resources, including vehicles.

Line Number
First Name
Resource Type
Total Value
Amount Owed
Resource Description

CQPERS
CQVEHL

Resources

Question #5 is not prepopulated. It asks for address and utility/shelter costs. The recipient will answer yes or no and may provide verification of changes.

The number of questions tracked and their placement on the form has changed. The CCMRTK tracking screen has also changed. (See SAR Tracking Form.)The CAO checks questions not answered and/or verified on the SAR form “incomplete.”

NOTE:  If the recipient has established good cause for not completing or returning the SAR form, narrate the reason for granting good cause. There is no Good Cause tracking line on the new SAR form.

Recipients must answer all questions and list any changes from the information printed on the SAR form. The SAR process has not changed. It is described in Chapter 23 of Using CIS.

Reissued August18, 2012, replacing January 31, 2012