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Appeal Request Form

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State of Illinois

Department of Human Services

APPEAL REQUEST FORM (SNAP, Medical Assistance, Cash Assistance, Child Care)

Use this form only if you want to file an appeal (this is a request for a hearing). Your Family Community Resource Center

(FCRC or local office) may help you fill out this form. You may file this form with your FCRC or with the Bureau of Hearings at

69 W. Washington, 4th Floor, Chicago, IL 60602 or via email at DHS.BAH@Illinois.gov, Fax at (312) 793-3387 or by

Telephone at (800) 435-0774.

Appellant Last Name

Appellant First Name

Telephone Number

Address (No. & Street, Apt. No.)

City, County

State, Zip Code

Name Case is Under

Case Number

Social Security Number

Yes

Will you need an interpreter in the hearing?

If Yes, what language?

Medical

AABD Cash

Child

I am appealing action taken on (check all that apply):

SNAP

TANF

Assistance

Care

Application/Request Date:

Department Date of Notice from which you are appealing:

I AM REQUESTING A FAIR HEARING BECAUSE:

My application/request was denied and I disagree with this

IDHS says I am not disabled and I disagree with this

I was enrolled in spenddown and I disagree with this

A penalty period was imposed and I disagree with this

I disagree with the benefit amount

I disagree with the beginning eligibility date

My benefits were stopped or reduced and I disagree with this

I was charged with an overpayment and I disagree with this

My SNAP benefits were recouped for a previous overpayment claim(s) and I disagree with this

Money was recovered on an overpayment claim(s) and I disagree with this

A sanction was imposed and I disagree with this

I asked to be exempt from the Department's work and training activities and I was denied

I requested Crisis Assistance and I was denied

IDHS has not taken action on my application or a request

Other Reason

IL 444-0103 (R-03-16) Appeal Request Form (SNAP, Medical Assistance, Cash Assistance, Child Care)

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Appeal Request Form

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