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VIRGINIA DEPARTMENT WAIVER OF ADMINISTRATIVE OF SOCIAL SERVICES DISQUALIFICATION HEARING

10/24 VOLUME V, PART XXIV, PAGE 89

WAIVER OF ADMINISTRATIVE DISQUALIFICATION HEARING

FORM NUMBER - 032-03-0722

PURPOSE OF FORM - To advise a household member suspected of having committed an intentional program violation (IPV) that the right to a hearing may be waived but the disqualification penalty will be imposed if the waiver is signed.

USE OF FORM – The local agency must complete the form and send it to determine if a waiver to the administrative disqualification hearing can be obtained before referring the case to the Hearing Authority. This form must be sent with the Notice of Intentional Program Violation.

NUMBER OF COPIES – Two.

DISPOSITION OF FORM - The local agency must provide a copy of the completed waiver to the individual suspected of committing an IPV and keep a copy.

INSTRUCTIONS FOR PREPARATION OF FORM - Complete the identifying information at the top of the form. Enter the amount of the overpayment or overpayment for the program involved. Complete the form with the date by which the form must be returned if the waiver is to be activated. Enter a date that is 10 days after the mailing date.

If the individual waives the right to the hearing, the individual must complete the rest of the form and return it to the local agency.

TRANSMITTAL #35