STATE OF WISCONSIN
DEPARTMENT OF CHILDREN AND FAMILIES Division of Management Services Write-off / Adjustment FormTO:Public Assistance Collection SectionP.O. Box 8938Madison, WI 53708-8938Fax: 608-422-7152 / Email: dwspacu@Date Submitted FORMTEXT ?????Section 1 (instructions on reverse side)From: Agency Name FORMTEXT ?????Telephone Number( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Agency Contact Name FORMTEXT ?????Agency Contact E-mail FORMTEXT ?????Liable Individual(s) FORMTEXT ?????PIN(s) FORMTEXT ?????Claim NumberAssistance ProgramError TypeOriginal Claim AmountAdjusted Claim AmountWrite-off / AdjustmentClaim Amount After AdjustmentAmount of Adjustment FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =IF(E2>0,E2-G2,D2-G2) \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =IF(E3>0,E3-G3,D3-G3) \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =IF(E4>0,E4-G4,D4-G4) \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =IF(E5>0,E5-G5,D5-G5) \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =IF(E6>0,E6-G6,D6-G6) \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =IF(E7>0,E7-G7,D7-G7) \# "$#,##0.00;($#,##0.00)" $ 0.00Total =D2+d3+D4+D5+D6+D7 \# "$#,##0.00;($#,##0.00)" \* MERGEFORMAT $ 0.00 =E2+E3+E4+E5+E6+E7 \# "$#,##0.00;($#,##0.00)" $ 0.00 =G2+G3+G4+G5+G6+G7 \# "$#,##0.00;($#,##0.00)" $ 0.00 =SUM(ABOVE) \# "$#,##0.00;($#,##0.00)" $ 0.00ExplanationSection 2 (instructions on reverse side)Explanation for Request: FORMTEXT ?????Reason / Justification for Write off / Adjustment (Check All Conditions That Apply)Section 3 (instructions on reverse side) FORMTEXT ????? RETAIN COMPLETED FORM IN CASE RECORDSection 1 Instructions Date: Date forwarded to Public Assistance Collection Section. From:Agency Complete Name.Agency Contact Name — Individual completing this form.Agency Contact Email – Individual’s email address who is completing this form.Agency Telephone—agency contact’s telephone number. Liable Individual:List all liable individuals where a write off or adjustment impacts the individual. (In bankruptcy if only one individual files and there are 2 liable individuals, list only the individual where the write off or adjustment should occur.) PIN(s):List the auto generated Personal Identification Number of the liable individuals. Claim Number:List the claim number assigned to the overpayment to be written off or adjusted. Assistance Program:List the category of assistance for the overpayment to be written off or adjusted. Error Type: List the error type of the overpayment to be written off or adjusted. Original Claim Amount:Amount of the claim as it was first created prior to any adjustments Adjusted Claim Amount:Amount of the claim after all previous adjustments have been made. Complete only when an adjustment has been previously concluded on the claim.Write-off / Adjustment Checkbox: Select whether the claim is to be Written off or adjusted. Claim Amount After Adjustment:What amount the claim should be adjusted to. Amount of Adjustment:Auto Calculated amount that has been adjusted or written off for each claim.Calculate Button: Selectable tool used to calculate the Amount of Adjustment and the Fields in the ‘Totals’ row. Totals:Auto Calculated sum of all columns.Section 2 Instructions Explain in det Explain in detail the justification for the write-off/adjustment request. Attach additional supporting documentation where appropriate. If the original claim amount was recalculated, please include copies of new worksheets and notices with this form.Section 3 Instructions Reason/Justification for Write-off/Adjustment:Check all conditions that apply. Where other conditions apply, a detailed explanation is necessary:Attach supporting documentation to support the reason/justification.The request will be returned to an agency if not properly completed or if supporting documentation does not exist.PLEASE SIGN BELOWAgency Requestor: (Name and Title) FORMTEXT ?????Date Signed FORMTEXT ????? RETAIN COMPLETED FORM IN CASE RECORD ................
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