Oral Request For Fair Hearing Form - Department Of Children And Families

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ORAL REQUEST FOR FAIR HEARING
[CBC or department staff will use th is form to document oral requests for fair h earings from young adults in accordance with 45 CFR
1355.30. A r equest for a fair hear ing ma y be or al or written, alt hough th e in dividual is encouraged to submit it in writing. This form
must be use d to docum ent a n oral r equest for a fair he aring. Within 2 4 hours of rec eipt of an ora l requ est, CBC staff shall fo rward
the form a nd a co py of th e original n otice of du e pr ocess to t he Region Ind ependent Livi ng Pr ogram Admin istrator, Reg ion L egal
Counsel, and to the Department’s Office of Appeal Hearings.]
FLORIDA DEPARTMENT OF CHILDREN & FAMILIES
Independent Living Fair Hearing Request
A hearing has been requested for:
_____________________________________________________________________
Name:
_____________________________________________________________________
Address:
_______________________________________________________________
City,
State, Zip:
______________________
_____________
Telephone
Number:
Social Security Number:
If applicable, enter "ext." and extension number
The ____________________________________________________ has decided to take the following action
regarding the individual’s eligibility for or receipt of Independent Living benefits:
The individual has stated that he/she is not satisfied with this action and is requesting a hearing for the
following reasons:
The
CBC’s
Department’s Representative is:______________________________________________
This hearing request must be faxed within 24 hours to the following address. A copy of the letter to which this
request pertains should accompany this request for hearing.
Department of Children and Families
Fax #: (850) 487-0662
Office of Appeal Hearings
1317 Winewood Boulevard
Tallahassee, FL 32399-0700
Name:
Address:
City,
State, Zip:
Telephone Number:
If applicable, enter "ext." and extension number
Date of Request:
Name & Telephone # of person taking request:
The Authorized Representative (if applicable) is:
Name:
Address:
City,
State, Zip:
CF-FSP 5303, PDF 09/2010, [65C-31.009, F.A.C.]

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