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VIRGINIA DEPARTMENT NOTICE OF DISQUALIFICATION FOR OF SOCIAL SERVICES INTENTIONAL PROGRAM VIOLATION

10/24 VOLUME V, PART XXIV, PAGE 98

NOTICE OF DISQUALIFICATION FOR INTENTIONAL PROGRAM VIOLATION

FORM NUMBER - 032-03-0052

PURPOSE OF FORM - To advise the household of a disqualification due to an intentional program violation.

USE OF FORM – The local department of social services must send this form to advise the household of the length, reason, effective date of a disqualification, and the benefit impact.

NUMBER OF COPIES - Two.

DISPOSITION OF FORM - Send the original to the household and keep a copy in the case record.

INSTRUCTIONS FOR PREPARATION OF FORM - Complete the form with information appropriate for the case and for the program involved. Enter the name of the disqualified individual.

TRANSMITTAL #35