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Effective Date: 



Updated: 1/2001


  • To serve as the official record of issues, facts, and decisions in administrative disqualification hearings.
  • To inform certification staff that a hearing officer in an Administrative Disqualification Hearing has or has not found a household member guilty of an intentional program violation.
  • To inform the household member that he has or has not been disqualified by a hearing and the time limits of the disqualification.
  • To dismiss a case without prejudice.


When to Prepare

The hearing officer completes Form H4857 when he makes the final decision in the case. The form must be sent within 10 workdays after making the administrative disqualification decision.

Number of Copies

An original and three copies; or when the client has a representative, an original and four copies.


If the household member committed an intentional program violation and the household member or representative was at the hearing, or if he or she is found not to have committed a violation, send the form to the household member with a copy each to:

  • Central Disqualification Unit (two copies),
  • the investigator, and
  • the household member's representative if applicable.

If the household member committed an intentional program violation, but the person or representative received notice and was not at the hearing, wait 10 days before distributing the form to give the person an opportunity to show good cause for failing to appear.

If the household member did not receive a notice of the hearing, the case may be dismissed without prejudice. Send Form H4857 to certification staff only.

Form Retention

The hearing officer keeps his copy for three years.

The food stamp case record copy is kept for three years after the case is denied.

All other copies are kept until no longer needed.


  1. Enter the case name and mailing address in the address box. Enter the date Form H4857 is sent. Enter the case number and name of the county in which the household is located.
  2. Enter the hearing officer's name, office address, and telephone number.
  3. Enter information identifying the hearing. Enter the name of the person accused of an intentional program violation, his OIG case number, and his SAVERR client number.
  4. Check the box indicating that the accused person did or did not commit an intentional program violation or that the case is dismissed. If the person did commit a program violation, check the appropriate box indicating the disqualification period.
  5. The hearing officer signs the form.