- 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.
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.
Send the original to the individual along with Form H4851-F. The copy is put into the case folder.
After the individual returns the form, keep it in the case record for three years after the last case action.
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.