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INSTRUCTIONS FOR HEARING NOTICE

This form is to be used by local agencies for purposes of notifying the household of the local agency’s decision of whether the request for a fair hearing will be granted.

Complete and mail this form to the household within five (5) days from the date of receipt of a written request for a fair hearing.

This form may be handwritten.

DISTRIBUTION:

Original copy - Mailed or given to the household. Second copy - Maintained in the case record.