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

Agreement to Waive Child Care Provider Hearing for Intentional Program Violation

(Important information on page 2)

Provider name: / Provider number: / Accused person’s name: / SSN or Tax ID number:
The Intentional Program Violation (IPV) is a separate issue from the overpayment.
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 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 IPV (Intentional Program Violation) hearing. Whether or not a hearing is held, you will have to pay back the amounts you should not have received.
If you do not want the IPV hearing you must sign this form and return it by:

Section A — Charges

The Department of Human Services (DHS) believes you broke program rules on purpose. This is called an Intentional Program Violation (IPV).

Section B — Summary of evidence

The evidence will include applications you submitted, forms informing you of your responsibility to follow Child Care Provider program rules and report correct information, and forms or documents showing what you told DHS. The evidence may also include correspondence and documents from other sources, supporting the charges that you intentionally violated program rules. To find out how you can get a copy of the evidence, call the number on page 2.

Section C—Penalty and warning

The penalty for an IPV is a minimum disqualification for a period of six months and until the overpayment amount has been repaid. This means you will not be considered eligible or paid as a childcare provider by DHS for at least six months.
The minimum penalty disqualification for this violation is:

Read the information on the back of this form before completing this Section!

Section D—Acknowledgment and signature

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 in Section C. 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 in Section C. I understand I must pay back any amounts I should not have received.
Accused person’s signature: I have reviewed and understand all pages of this document / Date:
If you need more information, please call: (Investigator’s name)
/ Telephone number: / Ext.:
Section E—If you sign this agreement
Signing this form will result in a Child Care Provider disqualification period (as shown in Section C), even if you do not admit to the charges. You will not be eligible to receive Child Care Payments during the penalty period. You will also not be eligible to receive Child Care payments until your overpayment is repaid.
The signing of this form, or the holding of a hearing, does not prevent the State or Federal Government from prosecuting you in civil or criminal court, or from collecting the overpayment.

Section F— If you have a hearing

It is important that you, or the person who represents you, be at the hearing. If not, the hearing officer will reach a decision using the information from the agency only. 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. (See Section B for more information about evidence.)
  • 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. (Request must be made at least 10 days before the scheduled hearing.)
  • Obtain a copy of the hearing procedures upon request.

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. To file 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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