Form Dpa 479 - Administrative Disqualification Hearing Waiver - Calworks/calfresh
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2State of California – Health and Human Services Agency
California Department of Social Services
IMPORTANT NOTICE
ADMINISTRATIVE DISQUALIFICATION HEARING
WAIVER – CALWORKS/CALFRESH
Read carefully. Signing this waiver may affect your rights.
Date: _______________
Hearing Number: _______________
_________________ believes that you, ____________________, committed an Intentional Program Violation
(IPV). This means that the county is alleging that you intentionally gave the county wrong information or you
intentionally did not tell the truth.
By “intentionally” the county means that you did it on purpose. For CalWORKs, this means you
also did it for the purpose of establishing or maintaining the family’s eligibility for CalWORKs or for
increasing, or preventing a reduction in, the amount of the grant. This resulted in an overpayment of
__________ in CalWORKs and/or an overissuance of _____________ in the CalFresh Program.
The county may seek a disqualification penalty even if there is no overpayment or overissuance.
Disqualification penalties for an IPV can be six months, 12 months, 24 months, 4 years, 10 years, or
permanent disqualification depending on whether this was your first, second, or third violation or based on the
circumstances of the violation. You may also be disqualified from one or both programs.
You have the right to an Administrative Disqualification Hearing (ADH). However, you may give up your right to
a hearing by signing page 2 of this notice. You do not have to admit that you committed an IPV. If you sign the
waiver, you will be disqualified from CalWORKs and/or CalFresh for the time period(s) indicated on the bottom
of this form. If you sign this form, no hearing will be held.
If you sign this waiver to give up your rights to the ADH, you should know:
• Your income and resources will still be counted when figuring the household’s eligibility and benefits even
though you have been disqualified.
• If there are other members in your household, your household’s CalWORKs and CalFresh may be lowered
or stopped during your disqualification period.
• You have the right to remain silent concerning the charge(s); but, anything you say or sign may be used
against you in a court of law.
• Signing this statement does not stop the County, State, or Federal government from prosecuting you for an
IPV in a court of law or from collecting any overpayment or overissuances.
• For CalFresh overissuances the amount you owe will be more because you will not be allowed the earned
income deduction.
If you decide NOT to sign this waiver of rights to the ADH hearing:
• Your current eligibility will not change, pending the hearing.
• If you do not sign the waiver, your hearing will be held whether or not you attend. If you do not attend, you
may wish to submit a statement to the county representative identified at the bottom of page two of this
notice. A decision will be sent to you based on the evidence presented.
• If the county is sending you this form before your hearing has been scheduled, you will receive the
date, time, and place in another notice from CDSS. If you sign this waiver, the penalties will be as
follows:
DPA 479 (12/17) Required Form – No Substitutes Permitted
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