Request For A Fair Hearing - Oklahoma Department Of Human Services Page 2
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213MP001E (H-1)
13MP001E (H-1)
Request for a Fair Hearing
Request for a Fair Hearing
I. Request. To be completed by OKDHS client.
I request an administrative fair hearing before an OKDHS administrative hearing officer
for the following reasons: Attach additional pages if more space is needed.
IMPORTANT NOTICE for recipients of assistance payments or
services
Your benefits may continue until the hearing decision is issued if:
• within ten days of the date of the notice of change or termination of your case,
you tell OKDHS you want to appeal and for your benefits to be continued; and
• OKDHS receives this form from you within ten days of the date OKDHS gave you
this form or mailed this form to you.
If you are appealing an overpayment, there will be no collection of the current
overpayment until a hearing decision is issued.
If you are receiving food benefits and your certification period expires before the
hearing decision is issued, your benefits will end, but you may reapply for food
benefits and have your current eligibility determined by your local HSC office.
If your benefits are continued and the hearing decision is not in your favor, a claim will
be made against you for all benefits received while the appeal was pending.
I want my benefits to continue until the hearing decision is issued. Yes
No
II. Signature. This form must be signed.
Signature of client
authorized representative
Date
Client's name (Print)
Name of signer (Print)
If representative, relation to client
Signer's mailing address
Page 2 of 2
Page 2 of 2
Revised 7-15-2008
Revised 7-15-2008
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