Form H4861, Receipt of Notice

Instructions for Opening a Form

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Effective Date: 11/2015


Updated: 11/2015


  • 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.

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.