The Withdrawal of Waiver of Administrative Disqualification Hearing Consent Agreement (IM-161A) must be provided with every IM-161 offered. The IM-161A 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
- instructions to the individual to return the form to the local FSD office within five business days of signing the waiver