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"FOOD STAMP HANDBOOK §3-1230 (Cont) FORMS AND INSTRUCTIONS _ Handbook

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

DFA 377.2 (12/83)

Your Mignt To_A.ppeal Lnis ACTION.

it you ara dissatisfied with the action described on the other How to Request a State Hearing sida, of any’ other county action, you may request a state

hearing before a Hearing Officer of the State Departmant The best way to request a haanng it to fill in snd send this

of Sociai Services. This hearing will be conducted in an entire notice ta:

informat manner to assure that everyone present is able to

speak freely. Your county or adoption worker can help you Office of the Chief Raferee

fequest-a hearing. if you decide to request a hearing you State Department of Sociai Services must do so WITHIN 90 DAYS OF THE MAILING DATE OF 744Pp Street Mail Station 6-100 THIS NOTICE,

Sacramento, CA 95814 FOOO STAMPS AND CASH AID#; If this action ¥ f . stops of reduces your food stamps or cash aid and number st Pubie neest bg pearing by calling the toll-free you ask for a hearing before the effective date of ° volte Inquiry and Response. the action, your benefits may continue unchanged \ under cartain circumstances until the hearing or Public Inquiry and Response (Public information} until you recaive your hearing decision:- Food Stamps .

will not continua past the end of your current Toll-Free Number: (800) 952-5253* certification period. .

For the Deaf Only To (a00} 952-a349°

You may have to dial "1" first,

Authorized Representative

You can represent yourself at the state hearing, You can aizo

be represented by a friend, attorney of any other parson, "The State Public Inquiry and Response Unit can Provide you but you are expected te arrange for the fepresentative with further information about your hearing rights or fites or yourself, You can get halp in jocating free legal assistance by other welfare-related matters. Aasistance is also available

calling the toli-free 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 Social Services 744 P Street, Mail Station 16-23 Sacramente, CA 86814

Request for a State Hearing

Nama . Phone number {ad Address Ghy ‘Stare Tip Code {am requesting a mate hearing becaume of an action by the welfare department of county reisted

tomy tamiyer (C) cash aid [2 food somos } meci-cat (7) Asontion Assistance Program Payments Riensons for my request: .

oO (apeak a language other than English and need an intecpeeter for my hearing, (The stale will provide the interpeater at nu cost le you.) Language Giaiect

i eh i and velve fequest @ mate hearing and your benefits continue unchanged. the county can recover 96 an overpayment the ca Ty eee amps the hewing decision finds you were not eligible for, you remain eligible tw receive cash akg ater the hearing. and you Rave no other income of resourced, your gram will be reduced by 10% each month until the full amount of such overpayment |e colbected, M you do awa other income or available property, the amount pour grant will be reduced sach month will be g peter,

rock here i you want your benefit reduced or discontinued now, a¢ described in this Notice of Action,

D conn and "DC rood sums, H you checked the boxias] snd the hearing decision i in your lever, ay leet benefits will be mede up.

Synsture Deve

Rleanonse Any iviorm avon Tra miormaton you pronde on this lorm ia needed te process your de so by Contecting Byvéhe Inquvy end feqyent for pb hearing and procensing may be delayed if you request YOU prawde may be shared wiih the county ereflare daparterent. vetth GB incomplete, A casa File will be setup by tne Chief Raterea You tha U.S Cepertment of Health and Human Berwces or the UG have 6 ght te examine the materials (hay make up the [ie aad may Sepenmant of Agneutiuce Authority WAKE 10986

NA Boch 3 Cash Ala/FS}

CALIFORNIA-DSS-MANUAL-SS

Rev. 1384 replaces Effective 2/15/84

Issue 2209