/ SHARED SERVICES
Office of Payment Accuracy and Recovery
Fraud Investigations Unit /

Agreement to Intentional Program Violation

Temporary Assistance to Needy Families (TANF — cash for families)

Supplemental Nutrition Assistance Program (SNAP — food benefits)

Waiver of Right to Hearing

Program: / Branch: / TANF case no.: / EBT case no.: / Worker ID:
Case name: / Accused person’s name: / Accused person’s SSN:
XXX – XX -

Section A— Charges

The Department of Human Services (DHS)believes you broke program rules.DHSbelieves you did this on purpose.When you break rules on purpose it is called an Intentional Program Violation (IPV).

Section B—Penalty and warning

There are penalties for an IPV.The penalty is being disqualified from the program or programs in which you broke the rules.Being disqualified means you will lose benefits for a period of time.The time period for a first offense is 12 months.The time period for a second offense is 24 months.The time period for a third offense is permanent.When you break certain SNAP rules the time period for a first or second offense may be 2 years, 10 years or permanently.DHS believes the penalty for this violation is:
TANF — cash for families: / SNAP — food benefits:
12 months2 years10 yearsPermanent / 12 months / 2 years / 10 years / Permanent

Section C—If you sign this agreement

If you sign this form you will be disqualified and your benefits will be reduced or ended.This will occur even if you do not admit to the charges.The disqualification will be in SNAP, TANF, or in both programs.Section B shows the program(s) you will be disqualified from and for how long.You will not be eligiblefor SNAP and/or TANFfor yourself during this time.You may be eligible for Medicaid.While you are disqualified, the rest of your household may be eligible for SNAP, TANF and/or Medicaid.You may still be prosecuted by the state or federal government in civil or criminal court. This may happen even if you sign this form or an IPV hearing is held.You will have to pay back the benefit amounts you should not have received. This will happen even if you sign this form or an IPV hearing is held. Your benefits will be reduced to pay back the amount you were not eligible for.
If you do not want the IPV hearing you must sign this form and return it by:

Section D—Acknowledgment and signature

Read the information on page 2 of this form before completing this Section!

You may avoid a hearing by completing this section. If you want a hearing, do not sign this form.
Check One / I admit to the charges as stated above. I understand that if I sign this form, DHS will impose the penalty period described on this page. I understand I must pay back any amounts I should not have received.
I do not admit that the charges as stated above are correct. However, I have chosen to sign this form. I understand that if I sign, DHS will impose the penalty period described on this page. I understand I must pay back any amounts I should not have received.
Accused person:I have reviewed and understand all pages of this document / Date: / Date of birth:
Head of household:(head of household must sign unless he/she is the accused person) / Date:
If you need more information, please call: (investigator’s name) / At telephone number:
-- / Ext.:
.

This is a final order and is not subject to judicial review. If you believe this order was obtained by fraud or duress, you can request DHS set aside this order. To do this you must request a hearing. The department must receive your hearing request within 90 days of the date of this order.

Read this page before signing the form

You have the right to talk to a lawyer about this form.If you do not have a lawyer, you can talk to your local Legal Aid office. You may call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 1-800-520-5292 for advice and possible representation.
You have the right to remain silent about the charges made. Anything you say or sign about these charges can be used against you in a court of law. We plan to hold an Intentional Program Violation (IPV) hearing. You will have to pay back the benefit amounts you should not have received. This will happen whether or not an IPV hearing is held. Other family or household members may also be responsible for repayment.If you are receiving benefits, your benefits will be reduced. For an IPV in SNAP the reduction is $20.00 or 20% per month. For an IPV in TANF the reduction is $10.00 or 10% per month. The monthly reduction is the larger of the dollar amount or percentage. DHS may increase your SNAP over-issuance amount, when an IPV is established. This is because you will lose any “earned income deduction” you were allowed for earnings you did not report on purpose. If this happens you will receive a notice.

If you have a hearing instead of signing this form

Hearings are held before an Administrative Law Judge (ALJ). The ALJ works for the Office of Administrative Hearings. The ALJ does not work for DHS. DHS will present evidence at the hearing. This evidence is used to support our belief that you intentionally violated program rules. The evidence may include, but not be limited to:
  • Applications you submitted;
  • Forms informing you of your responsibility to follow program rules and report correct information;
  • Forms or documents showing what you told DHS; and
  • Correspondence and documents from other sources.
To find out how you can see the evidence, call the number at the bottom of page 1.
It is important that you, or the person who represents you, be at the hearing. If not, the ALJ will reach a decision using the information from DHSonly. If you miss the hearing, you will have 10 days to state "good cause" exists for missing the hearing, and to ask for a new hearing.
You have the right to:
  • Look at the evidence DHS will use at the hearing. You may do this before and during the hearing.
  • View the contents of your case file, except for confidential material. Your case file may contain items you cannot view because they are confidential. Confidential items will not be used at the hearing and will not affect the ALJ's decision. If you have questions about confidential material, your branch office can explain.
  • Receive free copies of the portions of the case file that you need for the hearing.
  • Present your own case or have someone present your case for you.
  • Bring witnesses.
  • Argue your case freely.
  • Question any statement made against you.
  • Question any evidence against you.
  • Confront and cross-examine any witnesses against you.
  • Submit evidence.
  • Request a postponement of your hearing. You must do this at least 10 days before the scheduled hearing.
  • Ask for a copy of the hearing procedures.

The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs1, disability or sexual orientation2.
You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons. Tofile a complaint with the state, you can call the Governor’s Advocacy Office at 1-800-442-5238 (TTY 711) or write to their office at: Governor’s Advocacy Office, 500 Summer Street NE, E17, Salem, OR 97301, fax: 503–378-6532, email:
Equal opportunity is the law!
1SNAP clients are protected against political belief discrimination.
2Sexual orientation is protected by the State of Oregon, but not federal laws.
*** ACKNOWLEDGMENT: I have reviewed and understand all pages of this document ______(Accused person initials)

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