Page 106

FOOD STAMP HANDBOOK

63-1230 (Cont. _FORMS AND INSTRUCTIONS

Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued)

63-1230 DFA 377.7B (3/84)

Your Right to Appeal This Action

side, or any other county action, You may request a state

FOOD STAMPS AND CASH AIDt: If this action you ask for a hearing before the effactive date of humber of Public Inquiry and the action, your benefits may continue unchanged under certain circumstances until the hearing or until you receive your hearing decision. Food Stamps will not continue past the end of your current Toll-Free Numbe

rtifica ti iod. coretication perio For the Deaf Only Authorized Reprasentative

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

Sacramento, CA 95814

Hf you are dissatisfied with the action described on the other How to Raquest a State Hearing

hearing before a Hearing Officer of the State Department The best way to request a hearing is to fill in and send this of Social Services. This hearing wil! be sonducted in an entice notice ta:

informal manner to-assure that everyone present is abie ta .

Speak freely. Your county or adoption worker can help you Office of the Chief Referee

faquest a hearing. if you decide to request a hearing you State Department of Sociai Services

must do so WITHIN 80 DAYS OF THE MAILING DATE OF 744 P Street, Mail Station 6-100

THIS NOTICE,

Sacramento, CA 95814

stops or reduces your food stamps or cash aid and You may also request a hearing by calling the toll-free

Public inquiry and Rlesponse (Public intormation}

*You may have to dial “1 first,

be represented by 4 friend, attorney or any other person, The State Public inquiry and Response Unit can provide you but you are expected to arrange for the reprasentative with further information about your hearing rights or files or yourself. You can get help int locating free legal assistance by other welfare-raiatad matters. Assistance is also availabie calling the toll-frea 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 Sacial Services 744 P Street, Mail Station 16-23

Response. a

fe: (800) 952-5253° TOD (800) 952-8349*

Request for a State Hearing

Name {

Phone number

i

‘Address chy State

Zip Code

Cam requesting & state hearing because of an action by the welfare department of

county related

to my family’s: im Cash Aid Q Food Stamps im Medi-Cat O Adoption Assistance Program Paymants

Reasons for my request:

qo | speak a language other than English and need an intarpreter for my hearing, (The state will provide the interpreter at no cost to you.)

Language Dialect

Chack hare H you want your benatits reduced or discontinued now, ag described in this Notice of Action,

o Cash Aid oO Food Stamps. if you checked the box(es) and the hearing decision is in your favor, any lost benefits will be made up.

TH you request & state hearing and your benefits continue unchanged. the county can recover a8 an overpayment the cash aid and vaiue of food stamps the hearing decision finds you were not eligible for. if you remain eligible to receive cash aid after the hearing, and you have no other income of resources, your grant will be reduced by 10% each month untit the tut amount ef such overpayment is caliected. 'f you do have other income or available property, the amount your grant will be reduced each month wilt be greater.

NA Back 3 (Cash Aig/FS)

Signature Date

The information you provide on this form is needed to process your do 80 by contacting Public inquiry and Response, Any information request for a hearing, snd processing may be delayed Hf your request you provide may be shared with the county welfare department, with is incomplete, A cage file will be set up by the Chiat Reteras. You the U.S. Department of Health and Human Services, ar the U.S.

have a right to exsmine the materiais that make up the fife and may Department of Agricutture. Authority WRIC 10950.

Mente Yas SOS

CALIFORNIA-DSS-MANUAL-SS Rev, 1880h replaces

aa ae ee i eee LBSUS 2226

Effective 2/15/84

(MANUAL LETTER NO rata fA