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_ oe ""ESOD STAMP HANDBOOK ~ 321230 (Cont) FORMS AND INSTRUCTIONS __ Handbook 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

DFA 377.74 (3/84)

Your Right to Appeal This Action

Hf You are dissatisfied with the action described on the other How to Request a State Hearing side, or any other county action, you may request a state

hearing before a Hearing Officer of the State Department The best way to request @ hearing is to fill in and send this of Social Services. This hearing will be conducted in an entire notice to: informal manner to assure that everyone present is able to speak freely. Your county or adoption worker can heip you Office of the Chief Referee request a hearing. if you decide to raquest @ hearing you State Department of Social Services must eh heTHIN 90 DAYS OF THE MAILING DATE OF 744 P Street, Mail Station 6-100 tel . *

Sacramento, CA 95814 FOOD STAMPS AND CASH AIDt: If this action Fi , stops or.reduces your food stamps or cash aid and rou may Panne atest sagan by calling the tolt-free you ssk for a haaring before the effactive date of quiry ia . tha action, your benefits may continue unchanged under certain circumstances until the hearing or until you receive your hearing decision. Food Stamps

wiil not continue past the end of your current Toll-Free Number: (800) 952-5253 certification period.

Public inquiry and Response (Public information)

For the Deaf Only Top (800) 952-8349° Authorized Representative

*You may have to dial

You can represent yourself at the state hearing. You can aiso

be represented by a friend, attorney or any other Person, The State Public Inquiry and Response Unit can provide you but you are expected to arrange for the representative with further information about your hearing rights or files os yourself. You can gat heip in locating free iegal assistance by other weilfare-related matters. Assistance is also available calling the toll-free number of Public inquiry and Response. in some languages other than English, including Spanish.

You may phone, write or come in,

Public Inquiry and Response

State Department of Social Services 744 P Street, Maif Station 16-23 Sacramento, CA 95814

Request for a State Hearing

Name Phone number Lomb Address : Chy Stave 2ip Code fam requesting a state hearing because of an action by the welfare department af county related

to my family’s: im] Cash Aid Oo Food Stamps oO Medi-Cal im Adoption Assistance Program Payments Reasons for my request:

CI i speak 2 language other than English and need an interpreter tor my hearing. (The state will provide the interpreter at no cost te you,| Language Dialect

Ti you request a: state hearing and your banetits continue unchanged, the county can recover as an overpayment the cash aid and valve of food stamps the heering decision finds you were not siigibie for, If you remain eligible to receive cash aid atter the hearing, anc You have no other incoms or resources, your grant will be reduced by 10% each month until the full amount of such averpayment is collected. 4f you do have other income or available property, the amount yout grant will be reduced each month wilf be greater.

Check here if you want your benefits reduced or discontinued new, as described in this Notice of Action.

O Cash Aid mi) Food Stamps if you checked the boxias} and the hesring decision is in your faver, any fost benefits will be made up.

Signature * Date

The information you provide on this form ip neuded to procest your So 80 by contacting Public Inquiry and Response. Any information request for & hearing. and processing may be delayed if your request you provide may be shared with the county welfare department, with is incomplete. A cage file will be set up by the Chief Referee. You the U.S. Department of Health and Human Services. or the U.S, have a right to examine the materials that make up the {ile ard may Department of Agriculture. Authority WRIC 10960

NA Back 3 Cash Aid FS} NEO VE oe ES?

Rev. 1390c replaces . CALIFORNIA-DSS-MANUAL-SS issue 2221 Effective 2/15/84

PRA RRA mee