Fair Hearing Request
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1DEPARTMENT OF CHILDERN AND FAMILIES
FAIR HEARING REQUEST
Department of Children and Families
Office of Appeal Hearings
Fax #850‐487‐0662
Building 5, Room 255
Email: Appeal_Hearings@dcf.state.fl.us
1317 Winewood Boulevard
Phone #850‐488‐1429
Tallahassee, FL 32399‐0700
Dear DCF:
I would like to request a hearing before the Department of Children and Families
because of action taken regarding my eligibility for or receipt of benefits.
Name: _______________________________________SSN: ________________________
Address: ____________________________________________________________________
Type of Benefit: _________________________ Case#: ______________________________
No
LANGUAGE NEEDED:_______________
Translator requested:
Yes
Reason for hearing request:
I DO NOT AGREE WITH THE DEPARTMENT’S DECISION REGARDING MY CASE.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I understand that by appealing timely, my benefits will be continued at the level
received prior to this change.
Date:_____________
Signed:
_
My authorized representative is:
Name: ____________________________________________________________________
Address: ___________________________________________________________________
Phone Number: _____________________________________________________________
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Parent category: Business