STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Workforce Solutions F-16024 (07/08)
NOTICE OF DISQUALIFICATION
Personally identifiable information will be used only for the direct administration of Public Assistance Programs.
Name CARES PIN Address City Date Case Number State ZIP Code
You are being disqualified for the following program(s): Wisconsin Works (W-2) child care assistance (CC) You are being disqualified because: You were found guilty of Intentional Program Violation at an administrative hearing on You waived your right to an administrative disqualification hearing. You signed a Consent for Disqualification, as part of Prosecution Diversion Agreement. You were found guilty of Intentional Program Violation in a court of law. If 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.
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. 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.
Effective One (1) year because this was your first violation. Your W-2 payments will stop effective .
, you will be disqualified from FoodShare Wisconsin for: Two (2) years because this was your second violation. Your child care assistance will stop effective . Permanently because this was your third violation. Your FoodShare benefits will stop effective .
If you are not now receiving W-2, child care assistance or FoodShare you will be subject to the above disqualification penalties whenever you apply and are eligible for the programs again. If you are not satisfied with this decision, you may appeal it in a court of law. This decision does not prevent the state or federal government from prosecuting you for an intentional violation of a program rule in a court of law. Although you or a member of your household has been disqualified from participation, other members in the household may continue to be eligible for FoodShare benefits. Contact the W-2, county/tribal human or social services agency, if you wish to re-apply for these programs. If you have not had a Fair Hearing, you may request a Fair Hearing for child care payments or FoodShare benefits if you are not satisfied with the agency's decision. You may request a Fair Hearing in writing or in person with the local agency. You may also request a fair hearing by writing to the Department of Administration, Division of Hearings and Appeals, PO Box 7875, Madison, WI 53707-7875 or by calling 1-608-2663096. Your request must be received (1) within 45 days of the action's effective date for child care and, (2) within 90 days of the action's effective date for FoodShare Wisconsin or at anytime while you are getting FoodShare benefits, if you do not agree with the amount of your benefits. The request for a fair hearing for child care must be made separate from a request for fair hearing for FoodShare Wisconsin. If you are not satisfied with the a W-2 decision, you may request a Fact Finding Review by writing your worker or W-2 agency within 45 days of the decision date. If you have questions, contact your case worker. Distribution: Original Participant Case File Copy