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NOTICE OF NONCOMPLIANCE WITH IMPACT (EMPLOYMENT AND TRAINING) REQUIREMENTS
State Form 25385 (R6 / 4-09) / IMP 2210

Date (month, day, year) Rid number

Case number

FROM:

TO:

Our records show that you did not comply with an IMPACT Employment and Training requirement. The requirement was to:

on

,

at

or

for the month of

,

.

If you believe that there was good cause for not complying with this requirement, contact your Impact Case Manager as soon as possible. You may do this by filling out the bottom part of this notice and returning the entire notice to us at our office, or calling the Impact Case Manager at the telephone number listed below. The Impact Case Manager must be notified verbally or in writing by . If you do not contact us in time and/or if the reason you provide does not meet the good cause criteria, your assistance group may lose Temporary Assistance for Needy Families (TANF), Medicaid and / or Food Stamp benefits as marked below: TANF IMPACT MANDATORY Failure to meet IMPACT requirements without good cause may result in a loss of Medicaid benefits for the non-complying member and the entire assistance group will lose TANF benefits. If you now wish to meet the requirement, contact your Impact Case Manager at the telephone number below. FOOD STAMP MANDATORY WORK REGISTRANT / REFERRED TO TANF IMPACT Failure to meet IMPACT requirements without good cause may result in a loss of Food Stamp benefits for the non-complying member during the sanction (penalty) periods described below: a. The first time a requirement is not met, the sanction period is for 2 months or until the non-compliance stops, whichever is longer. b. The second time a requirement is not met, the sanction period is for 6 months or until the non-compliance stops, whichever is longer. c. The third time a requirement is not met, the sanction period is for 36 months or until the non-compliance stops, whichever is longer. You may avoid losing any Food Stamp benefits if IMPACT requirements are met before If you now wish to meet the requirement, contact your Impact Case Manager at the telephone number below.
Signature of Impact Case Manager Date signed (month, day, year) Telephone number

.

(
I did not comply with the IMPACT (Employment and Training) requirement because:

)

Signature of IMPACT client

Date signed (month, day, year)

DISTRIBUTION: White - Client; Canary - Case File