The individual may waive the ADH by signing a waiver form. The individual suspected of an IPV, and the head of the SNAP household, if different, may complete, sign and return the waiver form to the Department. By completing, signing and returning the waiver form, the individual and the household agree to all penalties and requirements, including repayment, incumbent upon a household containing a member who is found guilty of an IPV at an ADH. The waiver form shall include: (A) a statement that signing the form will result in automatic disqualification and recoupment; (B) the opportunity for the individual accused of an IPV to admit or not to admit the charges cited in the ADH advance notice; (C) a statement that neither the household nor the individual has the right to a subsequent fair hearing on the same issue(s), nor on the amount of the claim; (D) a statement that the remaining household members will be held responsible for the claim even if the household composition changes or the household stops participating in the program; (E) the name and telephone number of someone who can be of assistance if the accused should wish to discuss the charges, or the implications of the waiver; (F) a place for the individual and the head of household or authorized representative to sign the form; (G) a statement that failure to sign and return this form within the period specified by the Department will result in the holding of an ADH; (H) the charge(s) against the household member; (I) a summary of evidence and how and where it can be examined; (J) a listing of the household member's rights as described in 106 CMR 367.400; (K) a copy of the Department's ADH hearing procedures; and (L) a statement that failure to return this waiver shall in no way have a negative impact on the result of the ADH.