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§3-1230 (Cont,) _
63-1230 STATE FORMS & INSTRUCTIONS (Continued)
“FOOD STAMP HANDBOOK _FORMS AND INSTRUCTIONS
Handbook
63-1230
DFA 377.9 (3/81)
Your Right to Appeal This Action
{f you ure dissatisfied with the action described on the other side, or any other county action, you may request a state hearing before a Hearing Officer of the State Department of Social Services, This hearing will be conducted in an informal manner to assure that everyone present is able to apeak Freely, Your county worker can help you request a hearing, If you decide to request a hearing you must do so WITHIN 90 DAYS OF THE DATE OF THIS NOTICE,
AFDC: If your AFDC is being reduced or stopped and you ask for s hearing within 10 days of the mailin date of this‘notice, you can continue to receive AFD until the hearing.
FOOD STAMPS: If ion, food stamps are being reduced or stopped and you ask for x hearing within 10 days of the mailing date of this notice, your food stamps may continue until the hearing or until the end of ft current period of eligibility, whichever comes first, uniess you check the box at the bottom of the page,
Authorized Representative
You can represent yourseif at the state hearing. You can also be represented by a friend, attorney or any other person. but you are expected to arrange for the representative yourself, You can get heip in locating free jega! assistance by calling the toll-(ree aumber of Public Inquiry and Response.
How to Request a State Hearing
The best way to request a hearing is to fill in and send this entire fotice ta:
Office of Chief Referee
State Department of Social Services 744 P Street, Mail Station 19-36 Sacramento, CA 95814
You may also request 2 hearing by calling the toll-free number of Public Inquiry and Response.
Public Inquiry and Response (Public Information) Toll-Free Number: (806) 952-5253 * Telstypewriter (TTY) only: (800) 952-8349 *
“You may have to dial “!" firs,
The State Pudtic Inquiry and Response Unit can provide you with further information about your hearing rights of files or other weifare-retated matters. Assistance is also available 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, Mail Station 16-23 Sacramento, CA 958}4
Request for a State Hearing
Name
Phona number fo
Address
State Zip code
{am requesting a stace hearing because of an action by the welfare depariment of
Oarpc 0 Food stamps 0 Medi-Cal
county related 10
Reasons for my request:
\ speak a language other than English and need an interpreter for my hearing,
(The state will provide the interpreter at no cost to you]
Language
Dialect
Food Stamps: If any portion of foad stamps provided to you wile awaitin
ig the Rearing decision is determined to be an averissuance, the county
may recover the value of the averisiuance. If vou want 10 avoid the possibility of such an averssuance. vou muy chack the nox below:
Cs want my food eee eee inited OF Teduced to the new amount determined by (he county until the Rearing deomon, If the hearing decision is im my: Favor. the county will make up the vod stampa | lose as v result of checkiny this bere,
Signature
Pate
The information sou provide an chs lorm is needed to proves your reyuesl for a hearing, and provessing may be velayed if your request 1s incornpiete, A case tile will he set ug by ihe Chief Referee. Yau have 4
sontaeting Public Inuuiry und Respunse. Any intarmation vau pros ide muy he shured with the county wellare vepurtement, atch the LoS Department uf Health and Human Services. of the |S Deparment of
ment (0 examine the macerigis thar make up the file und may dase Ay Agnculture Autnorie Wail (0060 CALIFORNIA-DSS-MANUAL-SS Issue 2233 Issued 8/14/81
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