Form 2303, Notice of Spend Down (IHFSP)

Effective Date: 8/2011

Availability

English PDF: 2303.pdf

Spanish PDF: 2303-S.pdf

Instructions

Updated: 1/2012

Purpose

To inform the individual who is receiving services that acceptable receipts must be received to substantiate purchases made with In-Home and Family Support Program (IHFSP) funds.

Procedure

When to Prepare

Complete when the individual who is receiving services is placed on spend down at either the six-month review or recertification.

Number of Copies

One copy and one original.

Transmittal

The original is filed in the case record. A copy is provided to the individual or his/her personal representative.

Form Retention

Retain in the case record for three years after the case is denied or closed.

Detailed Instructions

Effective Date of Spend Down — Enter the first day after the six-month period that is being reconciled.

Amount Due in Subsidy Receipts or Repayment — Enter the amount of subsidy funds that have been placed in spend down.

Amount Due in Capital Expenditure Receipts or Repayment — Enter the amount of capital expenditure funds that have been placed in spend down.

Date Range of Acceptable Receipts — Enter the first day of the period being reconciled in the first blank and the last day of spend down in the second blank.

Due Date of Receipts or Repayment — Enter the date 60 days after the effective date of the spend down period.

The following receipts were submitted but are not acceptable for the stated reason — List the receipts submitted that did not meet IHFSP receipt requirements. Next to each receipt, note the reason the receipt did not meet requirements.

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