Documents
Instructions
Updated: 11/2015
Purpose
- To allow individuals to acknowledge they received a notice of an administrative disqualification hearing.
- To notify the hearing officer that the individual has received a notice of an administrative disqualification hearing.
Procedure
When to Prepare
The hearing officer sends the form with Form H4851-F, Notice of Administrative Disqualification Hearing.
Number of Copies
Type an original and one copy.
Transmittal
Send the original to the individual along with Form H4851-F. The copy is put into the case folder.
Form Retention
After the individual returns the form, keep it in the case record for three years after the last case action.
Detailed Instructions
Individual Name — Enter the individual's/suspect's name.
Appeal ID — Enter the Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) case number.
Case Number — Enter the Office of Inspector General case number.
Date — Enter the date the form was completed.