1145.000.00 DISQUALIFICATION FOR INTENTIONAL PROGRAM VIOLATION

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 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.