Appeal Request Form

Appeal Request Form
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I request to appeal the notice dated Date* that be effective for me under the following situation(s):
Please choose the one(s) suitable for your case.
Other
Please add a copy of the appealing notice.
Cancelof
I appeal that decision for the following reasons:
If I'm qualified, I'd like to keep my benefits during the appeal process:
Please list any specific accommodations you'll need for the hearing. (e.g. handicapped access or translator):
Signature:
Clear
Date Signed:
MonthDayYear
Date
APPEAL REQUIREMENTS AND IMPORTANT INFORMATION
1. If you have questions about why your benefits or services were refused, decreased, or terminated, please contact your case worker, district office, or the appropriate division.
2. Except for food assistance, all appeals must be made in writing.
3. Unless otherwise specified in the notice or decision that you are appealing, the Department must receive your Appeal Request within 30 days of the date on the written notice (90 days for food stamps).
4. If you need assistance completing the Appeal Request, please contact your case worker or the district office.
5. If you want your benefits or services to be continued while your appeal is pending, you must file your appeal within 15 days of the decision's date and contact your district office. Benefits can only be started, stopped, or adjusted at the district office. (Not all cases allow for continuation of benefits while an appeal is pending.)
6. If your benefits or services are extended while your appeal is ongoing and the Department's decision is affirmed after the hearing, you will be required to reimburse the Department for the benefits or services you received during that time.
7. To the Appeal Request, please include a copy of the notice/decision that you are appealing. If you do not give a copy of your notice/decision, the scheduling procedure will be delayed.
8. If your Appeal Request is accepted by the Administrative Appeals Unit, you will receive a Notice of Hearing at the location you indicated on the Appeal Request. The date, time, and location of your hearing will be listed on the Notice of Hearing.
9. You will receive a letter outlining why your Appeal Request was denied if the Administrative Appeals Unit does not accept your appeal. The letter will be mailed to the address listed in your Appeal Request.
10. While your appeal is pending, you must notify the Administrative Appeals Unit of any changes in your address or phone number. If we are unable to contact you, your Appeal Request may be denied or dismissed without a hearing.
11. You have the option of representing yourself at your hearing or having an attorney or someone else represent you. You will be responsible for paying an attorney if you engage one to represent you. Your legal fees will not be reimbursed by the Department.
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