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COUNTY_____________________________________ CAA CASE NO.

CAA NAME

FAIR ADMINISTRATIVE HEARING LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)

PART I - - IDENTIFYING INFORMATION

Claimant’s Name

Hearing Date

Claimant’s Address

Hearing Time

Present at the Hearing: (1) Hearing Officer

(2) Claimant

(3) Claimant’s Representative(s)

(4) Worker

(5) Others

PART II - - SUMMARY

Check if additional material attached to this form.

Issue at the Hearing:

Findings:

Recommendation(s) of Agency Hearing Officer:

PART III - HEARING DECISION (To be completed by the State Office)

Upheld

Reversed

Reason for Reversal

Action to be taken

LIHEAP-107 Reviewed 2024