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FOOD STAMP HANDBOOK

83-1230 (Cont.} ..fQRMS AND INSTRUCTIONS Handbook

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

DFA 377.1 (12/83)

Your MIgnt to Appeal. tines Action

Mf you ara dissatisfied with tha action described on the other How to Request a Stata ‘Hearing

side, of any other county action, you may request # state .

hearing before a Hearing Officer of the State Deparment The best way to request a hearing to fil in and send this of Social Services, This Rearing will be conducted in an entita notice to:

informal manner to assure that everyone present is abie to

Spaak freely. Your county or adoption warker can help you Office of the Chief Referas

request a hearing. if you decide to request s hearing you State Departmant of Social Services

Tis none tN 90 DAYS OF THE MAILING DATE OF 744 P Street, Mail Station 6-100

Sacramento, CA 95814 FOOD STAMPS AND CASH AIDf: If this action | | stops or reduces your food stamps or cash aid end You may fisa request & hearing by calling the toll-free you ask for a hearing before the effective date of number of Public Inquiry and Response. the action, your benefits may continue unchanged . under certain circumstances until the hearing or Public inquiry and Response {Public information} until you receive your hearing decision. Food Stamps ~

wili_not continue past the end of your current Toll-Free Number: {800) 952-5253° certification period.

For the Deaf Only too (800) 952-8349* Authorized Representative .

: “You may have to dial "1" first, You can reprasant yourself at the state hearing. You can also

be represented by 2 friend, attorney or any other person, The State Public inquiry and Response Unit can provide you but you ara expected to actange for the reprasentative with further information about your hearing rights of files or yourself, You car get heip in locating free legal assistance by other welfare-ralatad matters, Assistance is also evaitabie Calling the toll-free number af Public Inquiry and Response. in some fanguages other the English, including Spanish,

You may phone, write or come in.

Public inquiry and Response

State Depanmant of Social Servicer 244 P Street, Malt Station 18-23 Sacramento, CA B5816

Request for a State Hearing

Name Prone number [| Address City State Tig Code Lam requesting a state hawing because of an action by the wellare depariment of courrty ravi

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

oO Tapegk a language other than English and need an interpreter for my hearing, (The state will provide the interpreter at ne coat to pou.) Language Oistect

. you fequest 4 state hearing and your benefits continue Unchanged, the county can recover a8 sn everpayment the cath ¢id and vetue % food stamps the heering decision finds you were nt eligible far, Ef you remain eligible to recehg cash aid after the hearng., end you heve ne cther income or resowrons, your grant will be reduced by 10% sach month until the full amount of such overpayment lt collected, #f you do have other income or available property, the emount your grant will be reduced each month will be greater,

Check here # you want your benefits reduced or discontinued tore,

at described in this Notice of Acton.

. O Cash Aid Q Food Stamps Hf you checked tha box(es} and the hearing decision «in your favor, any jout benefits wilt be made up,

Signetuce . One ” The information you provide on this form is needed to process your do $0 by Contacting Pubic Inquiry and Response Any infer enetion, teauert for & hearing and processing mey be deleved # your tequast YOu promise may be shared with the county weltare departmeng, with is rncompiete, A case file will be sel up by the Chief Neleree You the US. Deoarimant of Heatin ang Human Semen of the US have & nghi to examine the materrals that make up the hie end may Deparment of Agrcuiture Autrority WEIC 10980.

NA Back 3 (Cash Ald/ FS}

ts,

Rev. 1379 replaces . CALIFORNIA-DSS-MANUAL-SS cue 2955 Effective 2/15/84

i