PURPOSE: The State is responsible for investigating any case of alleged IPV and ensuring that appropriate cases are acted upon either through administrative disqualification hearings or referral to a court of appropriate jurisdiction. The agency delegates the responsibility for investigation of an alleged IPV to the Department of Social Services, Division of Legal Services, Welfare Investigation Unit (WIU). This form is used to track discussion between WIU and FSD regarding a possible intentional program violation (IPV).
NUMBER OF COPIES AND DISPOSITION: An original copy of this form is generated by the Welfare Investigation Unit (WIU) to the county to start the tracking process. The dialog between FSD and WIU is recorded on the same form.
MANUAL REFERENCE:
Food Stamp Manual Section 1145.010.10-1145.10.20.15 - Disqualification for Intentional Program Violation
INSTRUCTIONS FOR COMPLETION - WIU completes the WIU to FSD section. FSD completes the FSD to WIU section of the sheet.
TOP SECTION OF THE FORM (Completed by WIU)
WIU INVESTIGATOR NAME: Enter the name of the WIU investigator.
TELEPHONE NUMBER: Enter the telephone number of the WIU investigator.
WIU OFFICE: Enter the name of the office where the WIU investigator is based.
ADDRESS: Enter the complete street address, city, state, and zip code of the WIU office.
COUNTY MANAGER NAME: Enter the name of the County Manager of the Family Support Division (FSD) office.
TELEPHONE NUMBER: Enter the telephone number of the county FSD office.
COUNTY OFFICE: Enter the name of the county FSD office.
ADDRESS: Enter the complete street address, city, state, and zip code of the county FSD office.
CASE NAME: Enter the name for the head of the claim, or the individual being referred for investigation.
CLAIM NUMBER OR REFERRAL: Enter the claim number or a referral date if there is no claim established.
DCN: Enter the 10-digit Departmental Client Number (DCN) of the head of the claim or the individual being referred for investigation.
WIU TO FSD - (Completed by WIU)
DATE: Enter the date this section is completed by the selected option.
FIRST CHECKBOX: Check the box then enter the phone number and the date for FSD to contact WIU.
SECOND CHECKBOX: Check the box then enter the phone number and date to contact WIU. Enter the individual for whom the intentional program violation is being discussed.
FSD TO WIU - (Completed by FSD)
DATE: Enter the date this section is completed in the left column.
FIRST SENTENCE: Enter the date of the discussion.
CHECKBOX SELECTION: Enter a check mark by the selection that best describes the decision discussed. Two selections require a date when WIU has agreed to contact the individual.
WIU TO FSD - (Completed by WIU)
DATE: Enter the date this section is completed in the left column.
CHECKBOX SELECTION: Enter a check mark by the selection that best describes the outcome of WIU contact with the individual.