Revocation Notice and Notification of Rights, SFN 1212 660-05-65-40

(Revised 1/1/09 ML 3174)

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Before any revocation of a license takes place, SFN 1212 must be completed and sent to the provider along with the documents listed below. Contact the Program Administrator of Adult Family Foster Care, Division, for guidance prior to initiation of this action.

1. The regional Human Service Center shall notify the provider of the intent to revoke a license by certified mail, return requested. (The return requested is essential to validate twenty calendar day time period.)*
2. A copy of the statutes and Department rules authorizing revocation must be given to the provider.
3. Specific reasons must be cited in writing.  (List each reason under "Notice of Intent to Revoke a License to Provide Adult Family Foster Care.") A copy of applicable statutes and Department rules must be given to the provider.
4. The provider must be given notice in writing of their rights. The "Notification of Rights" section addresses all requirements of the law (N.D.C.C. Section 50-11-08) regarding the provider's rights.

A copy of this form must be sent to the Division.

Copies of this form can be obtained from Division by contacting the AFFC Program Administrator.

Reference:  Administrative Code Chapter 75-01-03-06.1 (Appeals and Hearings) Computation of time.