Customer Contact Center Food Stamp/Family Medicaid Phase II ...

Call Center FS & FM Phase II PG February 29, 2008
Initial Application
REMA for UINC
*******************************************UINC***********************************************
**
10/05/2006 18:23; FICM Caseworker B123 123Z Fulton 555-555-555
Date of report:____________ Timely? Y/N [ ]
UCB/ SDX/BENDEX, document discrepancies:___ At initial application, no
discrepancies were found.
______________________________________________
Types of UI: __________________________________________________________
Date payment will
Begin: _________ End: ______________
If RSDI on another account? Name:
_____________________Relationship:________
Calculation for UI if paid other than monthly (or use UINC Cal)
:___________________________________________________________________
_
Reason any fluctuating income is not considered Rep:
__________________________
Was net used rather than gross?
Y/N [] If yes, explain: ____________________
If contributions, source:
________________________Duration:__________________
: ___________________________________________________________________
:___________________________________________________________________
_
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MESSAGE
13-bott
PG-42