Free Waiver of Administrative Disqualification Hearing, HCF 16039 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Workforce Solutions F-16039 (07/08)

SANC

WAIVER OF ADMINISTRATIVE DISQUALIFICATION HEARING
Personally identifiable information will be used only for the direct administration of Public Assistance programs. You have the right to an Administrative Disqualification Hearing prior to any action taken by the State of Wisconsin to disqualify you from receiving applicable benefits; Wisconsin Works (W-2), Child Care Assistance or FoodShare Wisconsin. If you wish, you may waive this hearing. A waiver of your disqualification hearing will result in the following: 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 may be permanently disqualified from your eligibility for Child Care Assistance.

You will be immediately disqualified from FoodShare Wisconsin for: One (1) year because this was your first violation. Additional information Your W-2 payments will stop effective Two (2) years because this was your second violation. Permanently because this was your third violation.

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Your Child Care Assistance will stop effective .

Your FoodShare benefits will stop Effective

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If you are not receiving W-2 or Child Care Assistance now, you will be subject to the above mentioned penalties whenever you reapply and are eligible for the programs again. If you sign this waiver, you must also choose one of the following statements to indicate whether or not you admit to the facts as presented above. You do not have to admit to any of the charges. You have the right to remain silent concerning the charges, as anything said or signed by you could be used in a court of law. I admit the facts as presented and understand that a disqualification penalty will be imposed if I sign this waiver, including a reduction in benefits during the disqualification period. I do not admit that the facts as presented are correct. However, I have chosen to sign this waiver and understand that a disqualification penalty will result, including a reduction in benefits during the disqualification period. The head of household must also sign this agreement if you are not the head of household. The individual accused of this intentional program violation, as well as the remaining household members, if any, will be held responsible for repayment of the resulting claim. This signed waiver must be returned to the W-2 or county/tribal human or social service agency listed below by: W-2, county/tribal agency Telephone Number ( ) City State ZIP Code .

Address

SIGNATURE ­ Participant

Date Signed

SIGNATURE ­ Head of Household (if different from participant)

Date Signed

Distribution:

Participant ­ Original

Case File - Copy

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