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Commonwealth of Virginia Department of Social Services NOTICE OF DISQUALIFICATION FOR INTENTIONAL PROGRAM VIOLATION
Name and Address
Case Name
Case Number
Locality
Date
This notice is to inform you of the disqualification of a person from the _____ Child Care Subsidy, _____ Supplemental Nutrition Assistance Program (SNAP) or _____ Temporary Assistance for Needy Families (TANF) program.
_________________________________ has been disqualified for the amount of time shown:
Child Care ______ 3 months _______ 12 months ______ Permanently
SNAP _____ months _____ Permanently _____ Other (specify)_____________________
TANF _____ 6 months _____12 months _____ Permanently
The reason for the disqualification is shown below:
_____ Court of appropriate jurisdiction found the person guilty of committing an intentional program violation of _____ Child Care, _____ SNAP, or _____ TANF policy.
_____ An Administrative Disqualification Hearing found the person guilty of committing an intentional program violation of _____ Child Care, _____ SNAP, or _____ TANF policy.
_____ The person waived his or her right to an Administrative Disqualification Hearing. The person had been informed that the disqualification penalty would be imposed.
The disqualification period will begin:
_____ For Child Care Subsidy program, effective __________________________________.
_____ For SNAP benefits, effective ___________________________________.
The SNAP allotment will change from $ _________ to $ _________.
_____ From the TANF program, effective _____________________________________.
_____ If this blank is checked, the disqualification will begin when the person next applies for and is found eligible for TANF.
The TANF payment will change from $ _________ to $ _________.
Worker
Telephone
For Free Legal Advice Call 1-866-534-5243 032-03-0052-13-eng (05/16)