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Commonwealth of Virginia Department of Social Services WAIVER OF ADMINISTRATIVE DISQUALIFICATION HEARING
Case Name
Case Number
Locality
Date
The Notice of Intentional Program Violation told you that we suspect you intentionally violated a program rule for Child Care, Supplemental Nutrition Assistance Program (SNAP), or
Temporary Assistance for Needy Families (TANF). The Notice listed the evidence against you.
The amount of benefits overpaid: $_____ Child Care $_____ SNAP $_____ TANF
This form is a WAIVER of an Administrative Disqualification Hearing (ADH).
IF YOU CHOOSE TO SIGN THIS WAIVER, you may indicate whether or not you admit the facts as presented in the Notice of Intentional Program Violation. Please note: You do not have to admit to any of the allegations.
If you choose to sign this waiver, please return it by _____ to avoid scheduling a hearing. Please return the form to:
Agency Name and Address
Worker
Telephone
For Free Legal Advice Call
1-866-534-5243
WAIVER You may check one of the following statements:
I admit to the facts as presented and understand that a disqualification penalty will be imposed and a reduction of benefits will occur if I sign this waiver.
I do not admit that the facts presented are correct. However, I have chosen to sign this waiver and understand that a disqualification penalty and reduction of benefits will result.
All members of your SNAP household are responsible for repaying the benefits overpaid.
Signature
Date
If you are not the case name, that person must also sign this waiver.
Signature of Case Name if Other Than You
Date
032-03-0722-06-eng (05/2016)