1145.055.20 Withdrawal of Waiver of Administrative Disqualification Hearing Consent Agreement (IM-161A) – DSS Manuals
IM-140 November 30, 2005
The Withdrawal of Waiver of Administrative Disqualification Hearing Consent Agreement (IM-161A) must be provided with every IM-161 offered. The IM-161A includes the following:
the name, mailing address, and DCN of the individual
the supercase number of the current EU
the DCN of the head of the EU, if different
the county office
the name and address of the hearing officer or WIU investigator who provided the IM-161 Waiver
the statement “I wish to withdraw my waiver of the Administrative Disqualification Hearing. I understand that the hearing will be conducted as if I had not signed the waiver.”
a space for the individual to sign and date the form
instructions to the individual to return the form to the local FSD office within five business days of signing the waiver