1145.055.00 INVESTIGATION/DISQUALIFICATION FORMS

IM-#140 November 30, 2005

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

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

1145.055.05 FSD/WIU Investigation Tracking Sheet

IM-#140 November 30, 2005

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 pdf logo 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 pdf logo to begin the tracking process.

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

IM-#140 November 30, 2005

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

The IM-160 Advance Notice contains:

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

IM-#140 November 30, 2005

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:

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.

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

IM-#140 November 30, 2005

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

The IM-161A Withdrawal includes the following:

1145.055.25 FAMIS Notices

IM-#68 July 26, 2013, IM-#140 November 30, 2005

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:

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:

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:

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.