Appeal To The State Department Of Social Services Form
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1Commonwealth Of Virginia
Department Of Social Services
County/City
Case Number
To
Hearing and Legal Services Manager
Virginia Department of Social Services
Name
801 East Main Street
Richmond, Virginia 23219-2901
Address
City, State, Zip
Appeal To State Department Of Social Services
To be valid/timely, SNAP (food stamps) appeals must be received within 90 days of written notice of the local agency decision. All other appeal requests
must be received within 30 days of written notice of the local agency decision. All appeal requests must meet appropriate deadlines as required by law.
There is no requirement that a request for an appeal for SNAP or TANF be made in writing. The request for an appeal for SNAP or TANF may be oral.
My appeal is in regard to the following program(s):
*
Temporary Assistance For Needy Families (TANF)
Energy Assistance (limited to items with an asterisk “
”)
SNAP Benefits (Food Stamps)
Services (e.g., Child Care)
General Relief
Refugee Cash Assistance
Refugee Medical Assistance
Auxiliary Grants
Other___________________________
Attention:
I hereby request a review of the (proposed) action of the Department of Social Services in the County/City of:________________________
for the reason(s) checked below:
Refusal to take my application for
Refusal to take my
Declaring me ineligible for
Declaring my household
assistance or services*
application for SNAP
assistance or services*
ineligible to participate in the
benefits
Supplemental Nutrition
Assistance Program (SNAP)
Suspending my assistance
Canceling my assistance or
Cancelling my SNAP benefits
or services
services*
Failure to take action on my
Failure to provide expedited
Failure to render a decision on my application for assistance
request for an increase in my
service on my SNAP case
or SNAP benefits within the allowable time limit:*
assistance or services which
was made on: _____________
Application was made on: ________________________________
Date
Date
Awarding me insufficient
Decreasing my SNAP
Decreasing my assistance from
$_________________
assistance of
benefit amount
to:
$_________________
$______________________
Decreasing my services _____________________________
From______________ days/hours to _____________ days/hours
Other (explain) _______________________________________________________________________________________________________
I believe I am eligible for assistance, services, or SNAP benefits or an increase in assistance or services or adjustment in SNAP benefits because:
I understand that any assistance and/or SNAP benefits received until a hearing decision is given must be repaid to the agency if the hearing
decision supports the action being proposed by the agency.
I wish my SNAP benefits to continue until a hearing decision is rendered:
Yes
No
I wish my assistance or services to continue until a hearing decision is rendered:
Yes
No
I received a written notice from the Social Services Department
Name/Address/Telephone of Claimant’s Legal Representative (if selected)
on (date)
Claimant Signature
Date
032-03-0024-10-eng (1/10)
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