Free Notice of FoodShare Overissuance, HCF 16028 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16028 (07/08)

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NOTICE OF FOODSHARE OVERISSUANCE
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First Notice Third Notice

Second Notice Notice

You were issued more FoodShare benefits than you were eligible to receive. The amount you were overissued is $ during this time period . By law, you must repay the overissuance checked below. The attached Repayment Agreement tells you how you can repay this overissuance. If this is your first notice, an Overissuance Worksheet is attached which shows how the overissuance was calculated. If you have also been underissued benefits, the amount you must repay has been reduced by the underissued amount (see line 22 on the worksheet). All adult members of the group that received the overissuance, are responsible for the overpayment.

Reason for this Overissuance ( )
Unintentional Household / Client Error: Sign and return the attached repayment agreement by . If your case is open and you do not return the agreement, we will reduce your benefits each month by 10% of your group's monthly allotment or $10, whichever is greater beginning the next benefit month. We will mail you a Notice of Decision 10 days before reducing your benefits. (A future administrative or court hearing may determine that this error is an intentional program violation. You will be notified if any administrative or court hearing will be scheduled.) Administrative / Agency Error: Sign and return the attached repayment agreement by . If your case is open and you do not return the agreement, we will reduce your benefits each month by 10% of your group's monthly allotment or $10, whichever is greater beginning the next benefit month. We will mail you a Notice of Decision 10 days before reducing your benefits Intentional Program Violation: Sign and return the attached repayment agreement by . If your case is open and you do not return the agreement, we will reduce your benefits each month by 20% of your group's monthly entitlement or $20, whichever is more, beginning the next benefit month. We will mail you a Notice of Decision 10 days before reducing your benefits. Closed Case ( ) Even though you are no longer receiving benefits, you must repay the overissuance described above. Sign and return the attached repayment agreement by .

Your Rights and Responsibilities:
You will have the right to request a fair hearing if you believe the agency's decision that you received a FoodShare overissuance is wrong or if you disagree with the amount of the overissuance. If your case is open, you will receive a Notice of Decision explaining your hearing rights and how to appeal. The notice explains that you can request a hearing orally or in writing, within 30 days of the action affecting your FoodShare benefits. If you request a hearing within 10 days after the FoodShare repayment is to begin, your benefits will not be reduced until a hearing decision is made. If your case is closed and you receive FoodShare benefits again, you will receive a Notice of Decision and can request a hearing as explained in the Notice of Decision. You have the right to request a fair hearing, if the amount of the overissuance was not established at a fair hearing. The request for a fair hearing must be made within 90 days of the effective date of the agency action or at anytime while you are getting benefits, if you do not agree with the benefit amount. If the overissuance is not paid, it will be sent to other collection agencies, which will use various collection methods to collect the overissuance. If this debt becomes delinquent the liable individual(s) may be subject to additional processing fees. You have the right to review and copy any records related to this overissuance. Your household can make a written agreement to repay the overissuance prior to it being referred for federal collection action. If the overissuance is not paid, it will be referred to the federal government for federal collection action. The State agency may reduce any part of the claim if the agency believes your household is not able to repay the claim. Free legal services may be available to you. Visit the Legal Action of Wisconsin web page at http://www.legalaction.org or call 1-888-2780633 or the Wisconsin Judicare, Inc. web page at http://www.judicare.org or call 1-800-472-1638, for information on services in your areas. SIGNATURE - Economic Support Specialist Agency Telephone Number (include area code)

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