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FOOD STAMP HANDBOOK _ _ §3-1230 (Cont) -FORMS AND INSTRUCTIONS = Handbook 63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230
NA 960X (1/84)
Your Right to Appeal This Action
4 you are dissatistied with the action described on the other side, of any other county action, you May request a state hearing before a Hearing Officer of the State Department of Sociai Services. This hearing wilt be conducted in an intarmnal manner to assure that everyone present is able to speek freely. Your county or adoption worker can help you request a hearing. if you decide to request a haaring you must do sa WITHIN 90 DAYS OF THE MAILING DATE OF THIS NOTICE,
FOOD STAMPS AND CASH AlOt+: Hf this action stops or reduces your food stamps or cash aid and you ask for a hearing before the effective date of 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 currant certification period,
How to Request a State Hearing
The best way to request & hearing is to fil! in and send this entire notice to:
\
Ojttice of the Chief Referee
State Department of Social Servicas 744 P Street, Mail Station 6-100 Sacramento, CA 95874
You may also request a hearing by calling the toll-free
number of Public inquiry and Response.
Public inquiry and Response (Public information) Toll-Free Number: (800) 952-5253* For the Deaf Only TDD (800) 952-8349*
“You may have to dial “1"" firsy,
Authorized Representative
You can represent yourself at the state hearing. You can aiso be represented by a friend, attorney or any other person, but you sre expectad to arrange for the representative yoursaif, You can get help in jocating free legal assistance by talling the toll-free number of Public inquiry and Response.
The State Public inquiry and Raspanse Unit can provide you with further information about your hearing rights or files or other weifare-related matters, Assistance is also availabie in some languages other than Engilish, including Spanish. You may phone, write or come in, Public inquiry and Rasponse
State Department of Social Services 744 P Street, Mail Station 16-23 Sacramento, CA 96814
Request for a State Hearing
Name Phone number i
Address City State Zip Code
1 arn requesting a state hearing because of ant action by the weitare department of
tomy tamity's: Ch cesraig 1 toog samos CI Mesi-cat Reasons for my request;
county related
C2 Adoption Assistance Program Payments
oO i speak a language other than English and need an interpreter for my hearing. (The state will provide the interprater at no cost to you} Language
Dialect
TH you tequest 2 state nearing end your benefits continue unchanged, the county can recover as an overpayment the cash aid and vaiue of food stamps the hearing decision finds you were not sligibie for. If you remain atigible to receive cash aid atter the Rearing, and you have no other incame or resources, your Grant will be reduced by 10% each month until the full amount of such overpayment is collected. it you do have other income or available property, the amount your grant will be reduced each month will be greater,
Check here if you want your benelits reduced or discontinued now, as described in thie Notice of Action.
o Cush Aid Oo Food Stamps Vf you checked the boxies} and the hearing decision fs in your favor, any lost benefits will be made ‘up.
Signature Date
The information yau provide on this form is needed to process your request for a hearing, and processing may be deiayed if your request i® Incomplete. A cage file will be sat up by the Chief Releres, You
do 80 by contacting Public Inquiry and Response. Any information you provide may be shared with the county weltare department, with: ihe U.S. Department of Health and Human Servicas, or the US.
have a rignt to examine the materisis that meke up the file and may NA Back 3 (Cash Aid/ FS}
Separiment of Agricuiture. Authority WAIC 10950.
CALIFORNIA-DSS-MANUAL-SS
Issue 652c
(MANUAL LETTFR NA a4.13a AIT
issued 2/15/84