STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Workforce Solutions F-16026 (07/08)
OP
Case Number
PROSECUTION DIVERSION AGREEMENT
Name (Last, First, MI)
I, $
agree to repay the following amount of Public Assistance Funds . I received this Public Assistance from (Date) to (Date) .
I agree to the following: 1. I agree to repay these funds instead of being prosecuted by the District Attorney/Prosecutor of , Wisconsin for Public Assistance Fraud. ,
2. By signing this agreement, I admit that I committed the crime of public assistance fraud in violation of Section 49.795 or 49.95 of the Wisconsin Statutes and that I willfully caused an overpayment of public assistance benefits to be made to me. 3. I understand I am admitting to committing public assistance fraud only for the purposes of this agreement. 4. I understand that my signature on this agreement cannot be used against me in court, should I violate conditions of this agreement. 5. By signing this agreement the of agency and the District Attorney/Prosecutor agency are not giving up their right
to initiate criminal prosecution of me if I violate the conditions of this agreement. 6. By signing this agreement, I agree that I have been informed and understand the Wisconsin Works (W-2), Medicaid and FoodShare Intentional Program Violation penalties and my right to a disqualification hearing. I waive my right to have a disqualification hearing and accept the disqualification penalty for this Intentional Program Violation according to federal and state regulations. 7. I further agree that instead of prosecution for welfare fraud under Section 49.795 or 49.95, I will repay the amount of at the rate of $ per month for months. I agree that if I miss one $ payment the W-2, County/Tribal Human or Social Services Agency or the District Attorney/Prosecutor or both may proceed with a charge(s) of public assistance fraud. I give up any right(s) I have, to be speedily charged with commission of a crime(s).
SIGNATURE Participant Date Signed
SIGNATURE Participant's Attorney
SIGNATURE - District Attorney
SIGNATURE - Fraud Investigator, Representative of W-2, County/Tribal Agency
SIGNATURE Judge (If applicable. For example pretrial or court order.)
Subscribed and sworn to before me this SIGNATURE Wisconsin Notary Public
day of
, 20
.
My commission expires on
.
Distribution:
Participant Original
County Fraud Investigator and Case File - Copy
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