Form H4851-F, Notice of Administrative Disqualification Hearing

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Effective Date
H4851-F.pdf (104.32 KB)
H4851-FS.pdf (104.93 KB)


Updated: 11/2015


To provide the household member with:

  • 30 days advance notice of the recommendation to disqualify him from the Temporary Assistance for Needy Families (TANF) program or the Supplemental Nutrition Assistance Program (SNAP); the reason for the recommendation; and the date, time and place of the hearing.
  • information about the administrative disqualification hearing and consequences of the hearing.


When to Prepare

The hearing officer completes Form H4851-F at least 30 days before the hearing date.

Number of Copies

Original and three copies.


Mail one copy to the investigator who submitted the case.

The hearing officer keeps one copy.

Mail Form H4851-F with:

  • Form H4855, Statement of Household Member's Rights in Administrative Disqualification Hearing/Procedures for Administrative Disqualification Hearing; and
  • an envelope addressed to the hearing officer.

Form Retention

Keep the case record copy for three years after the case is closed. File the form under the Legal Section in the case record. Destroy all other copies when no longer useful.

Detailed Instructions

Enter the household member's full name and address.

Date — Enter the date the form is typed.

OIG Case Number — Enter the Office of Inspector General (OIG) case number.

Individual Number — Enter the individual number of the household member who is being recommended for disqualification because of an intentional program violation.

Appeal ID — Enter the TANF case number or the SNAP case number.

Name of Hearing Officer — Type the name of the hearing officer.

Office Address and Telephone No. — Type or stamp the office address and telephone number of the hearing officer.

Day, Date, Time — Enter the day, date and time that the hearing is to be held.

Disqualification Period — Check the appropriate program and time period.