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Commonwealth of Virginia Department of Social Services REFERRAL FOR ADMINISTRATIVE DISQUALIFICATION HEARING

Locality

Case Number

Case Number

Child Care Violation 1 2 3 SNAP Violation 1 2 3 TANF Violation 1 2 3 IPV Period IPV Period IPV Period Overpayment Amount $ Overpayment Amount $ Overpayment Amount $

is alleged to have committed the following act(s) of intentional program violation:

We have the following evidence to support our case:

Copies of evidence to be presented at the hearing to prove the allegation are attached, including: 1) Verification or documents to support the charge; 2) Any applications for Child Care Subsidy, Supplemental Nutrition Assistance Program benefits or Temporary Assistance for Needy Families benefits signed by the accused during the time in which the intentional program violation allegedly occurred.

Information in this referral is provided with the knowledge it will be used in reaching a decision on the allegations made in this referral, and will be made available to the accused individual or representative.

Submitted by

Title

Telephone

Date

032-03-0725-05-eng (05/2016)