Page 591

Commonwealth of Virginia Department of Social Services ADVANCE NOTICE OF ADMINISTRATIVE DISQUALIFICATION HEARING

Name and Address

Case Name

Case Number

Locality

The local social service department has recently completed an investigation of your Child Care Subsidy case,

Supplemental Nutrition Assistance Program (SNAP) case, or Temporary Assistance to Needy Families (TANF) case.

The department believes you committed an intentional violation of a program rule because (continue on reverse, if necessary):

The department has the following evidence to support the case against you (continue on reverse, if necessary):

You or your representative may look at this evidence at the local social service department by calling your local worker to arrange a convenient time.

An Administrative Disqualification Hearing has been scheduled to examine the facts of your case. The hearing will be held at:

Time

Place

Date

If the hearing officer finds you intentionally violated a program rule, you will be disqualified from receiving benefits for the period shown below (the items checked apply to you):

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.

It is important that you or your representative be at the hearing. Otherwise a decision will be based solely on information provided by the local social service department. If you are unable to attend the scheduled hearing, you must contact the local social service department at least 10 days in advance of the hearing date. If you or your representative fails to appear at a scheduled hearing, you must contact the local social service department within 10 days after the date of the hearing and present good reason for your failure to appear in order to receive a new hearing. An explanation of the steps involved in a hearing is enclosed.

032-03-0724-08-eng (05/16) (continued on next page)