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)
PROSECUTION DIVERSION AGREEMENT
Name (Last, First, MI)
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
My commission expires on
County Fraud Investigator and Case File - Copy