1145.055.00 INVESTIGATION/DISQUALIFICATION FORMS

The following forms are used in the investigation, tracking and referral for disqualification for intentional program violation:

• FSD/WIU Investigation Tracking Sheet
• Advance Notice of Your Administrative Disqualification Hearing (IM-160 )
• Waiver Of Administrative Disqualification Hearing and Consent to Disqualification (IM-161 )
• Withdrawal of Waiver of Administrative Disqualification Hearing Consent Agreement (IM-161A )

The use of these forms is described in the following sections.

1145.055.05 FSD/WIU Investigation Tracking Sheet

When WIU completes the investigation and determines that there is sufficient evidence of an IPV, they may opt to pursue an administrative disqualification rather than go to court. The FSD/WIU Investigation Tracking Sheet is used to initiate discussion about the proposed disqualification due to a suspected program violation (SPV) or referral for investigation, and to track the communication between FSD and WIU.

The investigator sends the county the FSD/WIU Investigation Tracking Sheet to begin the tracking process.

1145.055.10 Advance Notice of Your Administrative Disqualification Hearing (IM-160)

If an ADH is being pursued, the IM-160 Advance Notice of Your Administrative Disqualification Hearing (IM-160 ) is prepared by FSD county staff and forwarded to the Hearing Unit when:

• FSD and WIU agree that the individual may have committed an IPV and
• the individual has not signed a waiver of hearing rights,

The IM-160 Advance Notice contains:

• the charge(s) against the individual EU member;
• a summary of the evidence, and how and where the evidence can be examined;
• the date, time, and place of the hearing;
• notification that a determination of IPV results in one of the following disqualifications:
  • For the first violation, a three month disqualification for the violation if the violation occurred prior to June 1, 1983; six month violation if the violation occurred on or after June 1, 1983; twelve month violation if the violation occurred on or after August 22, 1996.
  • For the second violation, a twelve month disqualification if the violation occurred on or after June 1, 1983; 24 month disqualification if the violation occurred on or after August 22, 1996.
  • The third violation results in permanent disqualification.
• a warning that the decision will be based solely on information provided by the FSD office if the EU member fails to appear at the hearing;
• a statement that the EU member or representative has ten days from the date of the scheduled hearing to present good cause for failure to appear in order to receive a new hearing;
• a statement that the hearing does not preclude the State or federal government from prosecuting the EU member for IPV in a civil or criminal court action, or from collecting the overissuance; and
• a statement that the individual can call the FSD office to obtain the name and phone number of someone who can provide free legal advice.

1145.055.15 Waiver Of Administrative Disqualification Hearing and Consent to Disqualification (IM-161)

The EU member(s) accused of an IPV may waive the right to an administrative disqualification hearing and consent to the disqualification by checking the appropriate box and signing the IM-161 Waiver of Administrative Disqualification Hearing Consent Agreement form. The right to waive the hearing is presented only one time. The waiver of Administrative Disqualification Hearing Consent Agreement form is only presented to an EU member accused of an IPV when:

• WIU completes the investigation;
• determines there is sufficient evidence of an IPV; and
• the investigator and county manager agree that the individual may have committed an IPV.

If WIU does not present the IM-161 Waiver, it is sent out with the hearing packet. It is not sent with hearing packet if WIU has already presented it.

The IM-161 Waiver includes the following.

• The fact that a waiver of the disqualification hearing results in a disqualification and a reduction in benefits for the period of disqualification, even if the accused individual does not admit to the facts as presented by FSD.
• A statement that the penalty remains the same whether the individual chooses to have a hearing and is determined guilty, or chooses to waive the hearing.
• An opportunity for the accused individual to specify whether or not s/he admits to the facts as presented, consisting of the following statements:
  • I admit to the facts as presented. I have chosen to sign the waiver/disqualification agreement and understand that a disqualification penalty and a reduction in benefits will be imposed.
  • I do not admit that the facts as presented are correct. However, I have chosen to sign the waiver/disqualification agreement with the complete understanding that a disqualification penalty and reduction in benefits will be imposed.
  • I have chosen not to waive the administrative hearing with the complete understanding that the hearing will be conducted as scheduled.
• A statement that the individual may withdraw the waiver within five business days by returning the enclosed IM-161A Withdrawal of Waiver of Administrative Hearing, and that the hearing will be conducted as scheduled.
• The fact that remaining EU members, if any, will be held responsible for repayment of the resulting claim.
• The claimant's right to remain silent.
• A signature block for the accused individual and the head of EU, if different.
• The date the signed waiver must be received by the Hearing Officer to avoid a hearing. This date may be the date of the hearing.
• The telephone number and name of the person to contact for additional information.

1145.055.20 Withdrawal of Waiver of Administrative Disqualification Hearing Consent Agreement (IM-161A)

The IM-161A Withdrawal of Waiver of Administrative Disqualification Hearing Consent Agreement must be provided with every IM-161 offered.

The IM-161A Withdrawal includes the following:

• the name, mailing address, and DCN of the individual,
• the supercase number of the current EU,
• the DCN of the head of the EU, if different,
• the county office,
• the name and address of the hearing officer or WIU investigator who provided the IM-161 Waiver,
• the statement "I wish to withdraw my waiver of the Administrative Disqualification Hearing. I understand that the hearing will be conducted as if I had not signed the waiver."
• a space for the individual to sign and date the form, and
• instructions to the individual to return the form to the local FSD office within five business days of signing the waiver.

1145.055.25 FAMIS Notices

FAMIS notifies the individual, in writing, when s/he is being disqualified by generating the FA-601 Informational Notice and automatically mailing the notice. The FA-601 Informational Notice notifies the EU:

• which individual is being disqualified,
• the reason for the disqualification, and
• the penalty for the disqualification.

FAMIS notifies the EU that the individual is being disqualified and how the action affects the food stamp case. The FA-510 Adverse Action Notice is sent advising the EU:

• what action will be taken,
• when the action will be taken,
• why the action is being taken, and
• of their hearing rights.

The EU may request a hearing due to the adverse action on the case. The hearing may be requested in person, in writing, or by telephone.  (Refer to instructions for the Application for State Hearing.)

If the FA-510 Adverse Action Notice is not put on hold or voided (refer to the Changing An Adverse Action Status user guide), the disqualified EU member is removed or the case closed. The FA-150 Claimant Action Notice is sent to the EU notifying the EU:

• what action was taken;
• the effective date for the action;
• the amount of benefits they will receive, if applicable; and
• of their hearing rights.

The FA-151 Food Stamp Budget Summary is included with the FA-150.  Forms can be viewed on the Document Queue (DOCQUE/FMVM) or Document History (DOCHST/FMVR) screens.