loading…
loading…
loading…
COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES
ADVANCE NOTICE OF PROPOSED ACTION
ACTION TO BE TAKEN ON YOUR CASE IS EXPLAINED BELOW. Case number Program
Date of Mailing: Call 1-866-534-5243, Legal Aid Hotline, for free legal assistance.
SNAP Benefits Your SNAP allotment will be: Reduced Suspended Terminated Effective Date:
Amount of reduction:
From:
To: Eligibility Worker:
Telephone:
Reason for Proposed Action: Manual Reference
FINANCIAL ASSISTANCE Your assistance check will be : Reduced Suspended Terminated Effective Date:
Amount of Reduction:
From: To: Eligibility Worker:
Telephone:
Manual Reference: Reason for proposed action: VIEW Termination – The TANF case is closed until you reapply and are found eligible for TANF/TANF-UP VIEW Sanction - your household's entire TANF or TANF-UP benefits will be suspended for the above reason. 1ST Sanction - 1 month and compliance 2ND Sanction - 3 months and compliance 3RD Sanction - 6 months and compliance YOU HAVE 10 DAYS AFTER THE DATE OF THIS NOTICE TO CONTACT YOUR VIEW WORKER TO SHOW DOCUMENTED GOOD CAUSE.
VIEW worker’s name Telephone:
While your TANF payment is suspended, any support paid to the Division of Child Support Enforcement (DCSE) in the month of suspension for you or your dependents will be mailed to you. If your case is reinstated, any support paid to the DCSE for you or your dependents will be kept by the state to repay TANF assistance received by your family.
If there is someone who is supposed to pay support for you or your dependents, you will continue to receive support enforcement services unless you send written notice that you do not want this service to the Division of Child Support Enforcement. You can obtain their address and telephone number from your local social services agency.
MEDICAID OR FAMIS PLUS No longer eligible for full Medicaid. Approved for limited Medicaid coverage: Qualified Medicare Beneficiary (QMB) Special Low-Income Medicare Beneficiary (SLMB) Qualified Individual (QI) No longer eligible for Medicaid.
No longer eligible for FAMIS PLUS.
No longer eligible for payment of long-term care because of transfer of assets.
_________________ Effective Date
____________________ Manual Reference:
_____________________________________________ Benefit Program Specialist:
_________________ Telephone:
Ineligible family members:
Reason for proposed action: Income exceeds the full Medicaid limit. If medical or dental expenses of $ _________________ are incurred between ________________ and ___________________ or medical or dental expenses of $ ______________ are incurred between _________________ and________________, bring your bills to this agency and your eligibility will be reviewed.
Other: ____________________________________________________________________________________________________________
If you disagree with the action we have proposed, you may appeal the decision. If you appeal this action before ____________________________, the change will not go into effect and your benefits for SNAP, General Relief-Unattached Child, or Auxiliary Grant Program may continue until a hearing officer makes a decision. If you appeal before ________________________________ for actions for the TANF, Refugee Assistance, Medicaid, or FAMIS PLUS Program, the assistance may continue. You may have to repay any assistance you get during the appeal process if the hearing decision supports the action we propose. You may appeal the decision proposed in this notice up to 30 days of this notice or by the effective date for Refugee Assistance, Medicaid, or FAMIS PLUS actions. You may appeal TANF, General Relief-Unattached Child, or Auxiliary Grants Program actions within 30 days of this notice. You may appeal SNAP actions within 90 days of this notice. See the back of this notice for additional information about appeals and fair hearings.
032-03-0018-34-eng (12/2023)