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VIRGINIA DEPARTMENT REFERRAL FOR ADMINISTRATIVE OF SOCIAL SERVICES DISQUALIFICATION HEARING

10/24 VOLUME V, PART XXIV, PAGE 91

REFERRAL FOR ADMINISTRATIVE DISQUALIFICATION HEARING

FORM NUMBER - 032-03-0725

PURPOSE OF FORM - To refer cases to the State Hearing Authority when an individual is suspected of having committed an intentional program violation (IPV).

USE OF FORM – The local department of social services worker must complete the form to provide information needed by the State Hearing Authority in order to initiate an administrative disqualification hearing. Mail the referral to:

Virginia Department of Social Services Hearings and Legal Services Manager 5600 Cox Road Glen Allen, VA 23060

NUMBER OF COPIES - Three.

DISPOSITION OF FORM - The local department must send two copies to the Hearings Manager and keep a copy.

INSTRUCTIONS FOR PREPARATION OF FORM - Complete the information requested at the top of the form. The IPV Period is the span of time over which the IPV occurred. This will often coincide with the dates over which a claim was established.

The " Overpayment Amount” is the total amount of the claim that relates to the IPV. If the IPV was due to an act that did not result in an overpayment, indicate "0" overpayment in this block. This may include, for example, misrepresenting the household's income on an application that was subsequently denied.

Explain the intentional act alleged and the evidence the agency has to support its claim. Evidence listed here must be made available to the individual and will be presented at the hearing. Confidential or other information restricted from the household cannot be the basis of the evidence to support the accusation of an IPV.

The department director or designee must sign the form.

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