121STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Economic Support F-16025 (07/08)
DISQUALIFICATION CONSENT AGREEMENT
Personally identifiable information will be used only for the direct administration of Public Assistance Programs. Name Address Case Number City State Date Zip Code
We believe you received Wisconsin Works (W-2), Child Care Assistance payments and/or FoodShare benefits to which you were not entitled by: a) intentionally making a false or misleading statement; b) intentionally misrepresenting or withholding facts; c) committing an act intending to mislead, misrepresent, or withhold facts. Your case has been referred to the District Attorney for prosecution for civil or criminal misrepresentation or fraud. There is evidence to support the following charge. You may defer prosecution by signing this disqualification consent agreement. By signing this agreement you will receive the penalty noted below for each program. The penalty will be imposed on the household for the disqualification period even though you have not been found guilty of civil or criminal misrepresentation of fraud. If you are 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 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. Receive three (3) strikes and may be permanently disqualified from your eligibility for Child Care Assistance.
If you are currently receiving Child Care Assistance, you will: Receive one (1) strike because this was your first violation. There is no disqualification period. Effective One (1) year because this was your first violation.
, you will be disqualified from FoodShare Wisconsin for: Two (2) years because this was your second violation. Permanently because this was your third violation.
You and the other members of your assistance group are responsible for repaying any W-2 payments or FoodShare benefits you received fraudulently. W-2 payments and FoodShare benefits will be reduced to recover the overpayment. To agree to disqualification, read the statement below and sign the agreement in the designated space. If you are not the head of the household, the head of the household must also sign this agreement. I understand that by agreeing to disqualification, the disqualification penalty or penalties described above will be imposed and I am waiving my right to an Administrative Hearing. SIGNATURE - Member Date Signed
SIGNATURE Head of Household
SIGNATURE Judge (required for W-2) or Prosecutor
Distribution: Member / Participant Original
Case File Copy
District Attorney - Copy