WITHDRAWAL OF WAIVER OF ADMINISTRATIVE HEARING DISQUALIFICATION CONSENT AGREEMENT
PURPOSE: Provides the individual an opportunity to withdraw the signed waiver of the Administrative Disqualification Hearing (ADH) and consent to disqualification. This form must be provided when an IM-161 Waiver of Administrative Hearing Disqualification Consent Agreement is signed by the individual or mailed to the individual. If the individual agrees to waive the ADH and then later changes his/her mind, the individual must sign the waiver withdrawal form within five days of signing the IM-161 and return the withdrawal form to the caseworker. The individual is allowed five days to withdraw the waiver, and another five days are allowed for mailing time for the IM-161A.
NUMBER OF COPIES AND DISPOSITION: WIU or the Hearing Unit provides a single copy of the waiver withdrawal form to the individual suspected of an intentional program violation (IPV) any time a waiver form is signed or mailed.
If the individual returns the waiver withdrawal form to the county office, immediately fax the IM-161A to the appropriate Hearing Unit or WIU office, as indicated on the form. Forward the signed original to the appropriate Hearing Unit or WIU office within 24 hours.
MANUAL REFERENCE: Food Stamp Manual section 1145.035.00
INSTRUCTIONS FOR COMPLETION: If WIU is offering the waiver/consent agreement, the investigator completes the IM-161A and gives it to the individual when the IM-161 is signed. If the Hearing Unit is sending the IM-161 with the hearing packet, the Hearing Unit completes the IM-161A and includes it in the hearing packet mailed to the individual. Complete the form as follows.
NAME OF INDIVIDUAL: Enter the name of the individual alleged to have committed the intentional program violation.
MAILING ADDRESS: Enter the mailing address of the EU.
CITY, STATE, ZIP CODE: Enter the city, state, and ZIP code for the mailing address of the EU.
INDIVIDUAL DCN: Enter the Departmental Client Number of the individual who signed the waiver of the ADH or the alleged violator.
SCN: Enter the supercase number of the EU with the individual, if applicable.
DCN (HEAD OF HOUSEHOLD, IF DIFFERENT): Enter the DCN of the head of the EU if different from that of the alleged violator.
COUNTY OFFICE: Enter the name of the county office.
HEARING OFFICER/INVESTIGATOR: Enter the name of the hearing officer or WIU investigator.
ADDRESS: The hearing officer or WIU investigator can either write his/her address, or use an address label with his/her address.
SIGNATURE: The individual accused of the IPV signs this form.
DATE: The individual enters the date this form is signed.