Free Administative Disqualification Hearing Notice, HCF 16038 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Workforce Solutions F-16038 (07/08)

SANC
Date Mailed to Member Case Number

ADMINISTRATIVE DISQUALIFICATION HEARING NOTICE
Name CARES PIN Address City

State

ZIP Code

We believe you received Wisconsin Works (W-2) payments to which you were not entitled by: intentionally making a false or misleading statement; intentionally misrepresenting or withholding facts; committing an act intending to mislead, misrepresent or withhold facts. Period in which you received W-2 payments incorrectly to . Amount of overpayment $ .

We believe you received Child Care Assistance to which you were not entitled by: intentionally making a false or misleading statement; intentionally misrepresenting or withholding facts; committing an act intending to mislead, misrepresent or withhold facts. Period in which you received Child Care incorrectly to . Amount of overpayment $ .

We believe you received Medicaid/BadgerCare Plus benefits to which you were not entitled by: intentionally making a false or misleading statement; intentionally misrepresenting or withholding facts; committing an act intending to obtain benefits to which you were not entitled. Period in which you received Medicaid incorrectly to . Amount of overpayment $ .

We have determined that you intentionally violated a FoodShare Wisconsin rule by misrepresenting eligibility to receive or attempt to receive FoodShare benefits you were not entitled to. engaged in trafficking or fraudulent use of FoodShare benefits. Period in which you received FoodShare benefits incorrectly Amount of overissuance $ The specific alleged violation is . to .

The following evidence supports this allegation

An Administration Disqualification Hearing has been scheduled to review this evidence and determine if the allegations are true. The date of the hearing is listed below. Your failure to appear at this hearing without good cause will result in a decision by the hearing officer based solely on the information provided by the local agency. Hearing Date Hearing Location Hearing Time

OVER Distribution: Member ­ Original Case File ­ Copy

Administrative Disqualification Hearing Notice F-16038 (07/08)

SANC

You or your authorized representative may review this evidence by contacting the person listed below to schedule an appointment. Agency Representative Telephone Number ( )

YOU HAVE THE RIGHT TO: ·
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Look at the evidence that will be used at the hearing both before and during the hearing. Please call the local county, tribal or W-2 agency if you wish to look at the evidence before the hearing. Present your own case or have someone present your case for you such as a lawyer, a friend, a relative or a community worker. Free legal services may be available to you. Visit the Legal Action of Wisconsin web page at www.legalaction.org or call 1-888-278-0633 or the Wisconsin Judicare, Inc. web page at www.judicare.org or call 1-800-472-1638, for information on services in your areas. Ask us to delay your hearing for up to 30 days if you need more time to prepare your case. To obtain a postponement, contact the Department of Administration, Division of Hearings and Appeals, PO Box 7875, Madison, WI 53707-7875, at least 10 days before the hearing. Obtain a postponement for a good cause reason within 10 days of the date of the hearing by contacting the Division of Hearings and Appeals at the address listed above. Bring your own witnesses. Argue your case freely. Question any evidence or statements made against you. Bring any evidence to the hearing that would support your case. Remain silent concerning the charges, as anything said or signed by you could be used against you in a court of law. Waive your right to an Administrative Disqualification Hearing by contacting your worker to complete a waiver form (HCF 16039) and agree to all of the consequences on that agreement.

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This hearing does not preclude the District Attorney from prosecuting you for an intentional program violation in a civil or criminal court action, or from the agency collecting an overpayment. The individual and the remaining members of the assistance group will be responsible for the repayment of the overpayment. If the hearing officer decides that you intentionally violated a program rule: And you are currently receiving W-2, you will Receive one (1) strike because this was your first violation. There is no disqualification period. Receive two (2) strikes because this was your second violation. There is no disqualification period. Receive three (3) strikes and be permanently disqualified from your current W-2 employment position.

And you are currently receiving Child Care Assistance, you will: Receive one (1) strike because this was your first violation. There is no disqualification period. Receive two (2) strikes because this was your second violation. There is no disqualification period. Receive three (3) strikes and may be permanently disqualified from your eligibility for Child Care Assistance.

You will be immediately disqualified from FoodShare Wisconsin for: One (1) year because this was your first violation. Two (2) years because this was your second violation. Permanently because this was your third violation.

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