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Commonwealth of Virginia Department of Social Services

NOTICE OF INTENTIONAL PROGRAM VIOLATION

Name and Address

Case Name

Case Number

Locality

Date

An investigation of your _____ Child Care Subsidy, your _____ Supplemental Nutrition Assistance Program (SNAP), or your _____ Temporary Assistance for Needy Families (TANF) case has recently been completed. We have reason to believe you intentionally violated a program rule because:

We have the following evidence to support our case against you:

We will request an Administrative Disqualification Hearing (ADH) to determine if you or another person in your household should be disqualified from Child Care Subsidy, SNAP, or TANF benefits. Please tell me if you have a disability or limited ability to speak and understand English or if you need special arrangements made so you can attend or present your case at the hearing.

You or your representative may look at the evidence we have. Please call the number below to arrange a convenient time to come to the local social services department to see the evidence.

You have the right to an ADH before we take any action to disqualify you from receiving benefits. However, if you wish, you may waive your right to this hearing. If you sign the attached waiver, you will be disqualified from receiving benefits for the period shown below even if you do not admit the facts as presented.

Child Care Subsidy _____ 3 months, 1st violation _____ 12 months, 2nd violation _____ permanently, 3rd violation

SNAP _____ months, 1st violation _____ months, 2nd violation _____ permanently, 3rd violation _____ Other (Specify) TANF _____ 6 months, 1st violation _____ 12 months, 2nd violation _____ permanently, 3rd violation

If you are not receiving TANF benefits now, you will be subject to the above disqualification penalty whenever you apply for TANF and are found eligible for TANF benefits again.

If you do not sign the attached waiver, an Administrative Disqualification Hearing will be held. If the hearing finds that you committed an Intentional Program Violation, you will be disqualified for the same period as shown above.

Please note that neither signing the attached waiver nor holding the hearing will prevent the State or Federal government from prosecuting you for an Intentional Program Violation in a criminal or civil court action, or from collecting the overpayment. You have the right to remain silent about the allegations as anything said or signed by you could be used against you in a court of law.

Benefit Program Specialist

Telephone

For Free Legal Advice Call

1-866-534-5243

032-03-0721-12-eng (09/2024)