Page 134

83-1230 (Cont) _

"FOOD STAMP HANDBOOK __-FORMS AND INSTRUCTIONS Handbook

63-1230 STATE FORMS & INSTRUCTIONS (Continued) 63-1230

NA 960Y (1/84)

Your Right to Appeal This Action

if you are 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 tha State Department of Social Services. This hearing will be conducted in an informal manner to assure that averyone present is abie to speak freely. Your county or adoption warker can help you request a hearing. If you decide to request a hearing you must do so WITHIN 90 DAYS OF THE MAILING DATE OF THIS NOTICE,

FOOD STAMPS AND CASH AIDt: If 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 tha end of your current certification period,

How to Request a State Haaring

The best way to request a hearin;

@ is to fill in anc sand this entire notica ta:

Office of the Chief Referee

State Department of Social Services 744 P Street, Mail Station 6-100 Sacramento, CA 95814

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 Too (800) 952-8349° Authorized Representative

“You may have to dial "1" first, You can represent yourself at the state hearing. You can also be represemed by a friend, attorney or any other person, but you are expected to arrange for the representative yoursalf, You tan gat help in locating free tegal assistance by calling the toll-free number of Public Inquiry and Response.

The State Public inquiry and Response Unit can provide you with further information about your hearing rights or files or other welfare-related matters, Assistance is iso available in some languages other than English, ingtuding Spanish, You may phone, write or come in,

Public inquiry and Response

State Department of Social Services 744 P Streat, Mail Statian 18-23 Sacramento, CA 95814

Request for a State Hearing

Name

Phone number {i State Zip Code

Address City

! am requesting a state hearing because of an action by the welfare department of

to my famiy’s: Ed cash aid (rong stamos 0) Megi-cal Reasons for my request:

county related © aseotion assistance Program Paymants

Oo | Speak a

language other than English and need an interprater for my hearing. (The state will provide the interpreter at Fa cost te you.) Language

Dialect

tif you requast a state hearing and your benefits continue unchanged. th

of food stamas the hearing decision finds you were not aligitie for vou have ne other income of resources, your grant will be reduead by 10% each month until the ful

6 county can recover a6 an overpayment the cash aid and vsiue It you remain eligible to receive cash aid ater the hearing, and amount of such overpayment is collected.

If you do have other income ar svaiiabie property, the amount your grant will be reduced aach month wilt be greater,

Check here if you want your benatits reduced or discontinued now, as described in this Notice of Action,

C1 cash aie : Vt you checked the boxies) and tha hearing dacision is im your favor,

7 Food Stamos any lost benefits will be made up.

Signature

Date *

The information you provide an tnie form is needed to process your requent for # heari 3 processing may be delayed if your requast is incomplete. A file will be set up dy the Chiet Reterse, You Rave e right to axaming the matariais that make up the file and may

do so by contacting Public inquiry and Response, Any information You provide may be snared with the county welfare department, with tha U.S, Department of Heath and Human Services, of the U.S.

Department of Agricutture, Authority W&IC 10980, NA Back 3 (Cash Aid / FS}

CALIFORNIA-DSS-MANUAL-SS

Issue 652

Issued 2/15/84