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FOOD STAMP. HANDBOOK

£12120 (Cont) FORMS AND INSTRUCTIONS

63-1230 STATE FORMS & INSTRUCTIONS (

re

__.Handbook

Continued) 63-1230 DFA 377.4 (12/83)

certification period,

Authorized Representative

Your mignt to Appeal This Action |

if you are dissatistied with the action described on the other How to Request a State Hearing

of Social Services, This hearing will be conducted in an entire notica to:

informal manner to ®ssure that everyone present is able to

speak freely. Your county or adaption worker can help you Office of the Chief Rateree

faquest & hearing. Hf you decide fo request a hearing you State Cepartment of Social Services must do to WITHIN 80 DAYS OF THE MAILING DATE OF 744 P Street, Mail Station 6-100

HIS Ni fos

FOOD STAMPS ANO CASH AID}: Hf this sction stops or reduces your food Stamps or cash aid and - . i

you ask for a haaring before the effective date of number of Public Inquiry and Response, the action, your benefits may continue unchanged under certain cleumstances until the hearing of until you recaive your hearing decision, Food Stamps will not continue Past the end of your current

You can represent yourself at tha state hearing. You can atso be represented by a friend, attorney of sny other parson, you are expected to arrange for the representative yourself, You can gat help in locating free legal assistence by calling the toll-free number of Public inquiry and Response,

The best way to foquest & hearing is to {iit in and send the

Sacramento, CA 95814

You may aiso request # hearing by calling the toll-free

Public Inquiry and Response {Public Information} Toll-Free Nurnber: (800) 952-5253° For the Deaf Only Tod (800) 952-a349+

*You may have to dial “1” firas,

The State Public Inquiry and Response Unit can Provide you with further information about your hearing rights or files of other wellare-raiated matters, Assistance is also evaltabie in some languages other than English, including Spanish. You may phone, write or come in,

Public inquiry and Response

State Deparment of Social Services

744 P Street, Mait Station 48.23

Sscramento, CA 96814

Request for a State Hearing

Nome Phone number tt Address City Stare Zp Code fam requesting a state hearing because of an action by the weifare department of county retated

9 pry famity‘e Oo Cash Aid QO Food Stamos. 0 Medi-Cat a Adoption Assistance Program Payments

Reasons for my request:

i { speak # language other than English and need an interpreter for my hearing, (The state will pronde the Wntee preter at NO COR tO yous.)

Language ©

Bieinc

Check hers 4 you want your benefits reduced or discontinued naw, #8 described in this Notice of Action,

NA Back J (Cann Aki/FS)

a a) Cash Ald oO Food Stamps

you checked the boxies} snd tha hasring decision is in your favor, ony lost benefits will be made wp. Segnawure Dare

i Inquxy and Reaponne. Any intormation The miormation you provide on this form is needed to process your do 40 by contacting Publ reaver for a hearing and processing may be delayed if your request YOu Bromide may be shared with the county welste department, with is incomplete. A cane fla will be sat up by the Chief Referes, You ihe U.S Sepactment of Health and Human Servcea or the U6 hawe a night to examine the materiats that make Up the fle and may Department of Agreulture, Authority WAKE 10980.

im oes ee

CALIFORNIA-DSS-MANUAL-SS

Rev. 1388 replaces __lssue 2213 _ . Effective 2/15/84

IMANHIAD terres an o¢ an, feel