North Carolina ______________County Department of Social Services
NOTIFICATION OF RIGHT TO REQUEST AN UNDUE HARDSHIP WAIVER
(TRANSFER OF ASSETS)
Notice Date:____________
Case Name and Address:
__________________________________
Medicaid ID Number:__________________
__________________________________
__________________________________
Case Number:___________
__________________________________
We have determined that on (date(s))_______________________ you/your spouse transferred (item(s))
___________________ valued at $_____________. The difference between this value and the amount actually
received ($_________) is $____________. This amount is considered to be the uncompensated value. This
results in a sanction period from _________ to ________ during which you are ineligible for institutional
services.
Either you did not earlier rebut this decision or, after a rebuttal review, the penalty was reduced to the amount
noted above or the rebuttal was denied.
You now have a right to request a waiver of this sanction period if you can prove that it will result in an
undue hardship. To request a waiver you or your representative must notify the below named
caseworker either in writing or verbally by the date noted below. The facility in which you reside may
request a waiver on your behalf with written consent from you or your representative.
In order to be determined eligible for an undue hardship waiver you must demonstrate that denial of payment by
Medicaid will cause you undue hardship. The burden of proof to show an undue hardship exists is your
responsibility, your representative’s responsibility, or the facility’s responsibility where you reside provided you
gave written consent. See the back side of this notice for a fact sheet explaining what undue hardship is and
some documentation that may be provided.
You have until _______________, which is 12 calendar days from the date of this notice, to request the undue
hardship waiver. If you contact your worker by this date you will be notified regarding what information you
need to provide to document your claim of undue hardship. Failure to contact your caseworker by this date to
request an undue hardship waiver will result in imposing the sanction period or denial of institutional services.
Contact your caseworker if you need an additional 12 calendar days to provide the documentation.
_______________________________
Caseworker Name and Phone Number
DMA-5113 (
11/07)
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