Free Prosecution Diversion Agreement, HCF 16026 - Wisconsin


File Size: 251.1 kB
Pages: 1
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHFS
Word Count: 393 Words, 2,558 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F16026.pdf

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STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Workforce Solutions F-16026 (07/08)

OP
Case Number

PROSECUTION DIVERSION AGREEMENT
Name (Last, First, MI)

I, $

agree to repay the following amount of Public Assistance Funds . I received this Public Assistance from (Date) to (Date) .

I agree to the following: 1. I agree to repay these funds instead of being prosecuted by the District Attorney/Prosecutor of , Wisconsin for Public Assistance Fraud. ,

2. By signing this agreement, I admit that I committed the crime of public assistance fraud in violation of Section 49.795 or 49.95 of the Wisconsin Statutes and that I willfully caused an overpayment of public assistance benefits to be made to me. 3. I understand I am admitting to committing public assistance fraud only for the purposes of this agreement. 4. I understand that my signature on this agreement cannot be used against me in court, should I violate conditions of this agreement. 5. By signing this agreement the of agency and the District Attorney/Prosecutor agency are not giving up their right

to initiate criminal prosecution of me if I violate the conditions of this agreement. 6. By signing this agreement, I agree that I have been informed and understand the Wisconsin Works (W-2), Medicaid and FoodShare Intentional Program Violation penalties and my right to a disqualification hearing. I waive my right to have a disqualification hearing and accept the disqualification penalty for this Intentional Program Violation according to federal and state regulations. 7. I further agree that instead of prosecution for welfare fraud under Section 49.795 or 49.95, I will repay the amount of at the rate of $ per month for months. I agree that if I miss one $ payment the W-2, County/Tribal Human or Social Services Agency or the District Attorney/Prosecutor or both may proceed with a charge(s) of public assistance fraud. I give up any right(s) I have, to be speedily charged with commission of a crime(s).
SIGNATURE Participant Date Signed

SIGNATURE Participant's Attorney

SIGNATURE - District Attorney

SIGNATURE - Fraud Investigator, Representative of W-2, County/Tribal Agency

SIGNATURE Judge (If applicable. For example pretrial or court order.)

Subscribed and sworn to before me this SIGNATURE Wisconsin Notary Public

day of

, 20

.

My commission expires on

.

Distribution:

Participant Original

County Fraud Investigator and Case File - Copy

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