Form Doh-10 - Request For An Appeal 2015
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1
2Request for an Appeal
If you have trouble reading or understanding this notice, call DTA at 1‐877‐382‐2363 for help.
What is an appeal? If you disagree with a Department (DTA) action, you have the right to appeal. If you appeal, you will have a
hearing. Hearings are usually held in your local DTA office. If you cannot come to the office, you can have a phone hearing. An
independent hearing officer will make the decision. At least ten days before the hearing, you will get a notice of the time and
place of the hearing. At the hearing, a DTA employee will explain the reason for the DTA action. You or someone helping you
can explain why you disagree with the action. After the hearing, the hearing officer will mail you a decision.
Can I bring someone to help me? Yes. You can bring anyone you want to support or represent you. You can also bring witnesses
to testify. You may be able to get free legal help. Call the Legal Advocacy and Resource Center (LARC) at 1‐800‐342‐5297 or go
to
How do I appeal? Fill in the spaces below.
Date___________________
I wish to appeal the following decision by DTA: ____________________________________________________________
___________________________________________________________________________________________________
Your Name (Print) _____________________________________Agency ID or last 4 of SSN____________Date__________
Address_________________________________________________________ Telephone ( ) _____________________
City/ZIP____________________________________________________________________________________________
If you have someone to help you with this appeal, please fill in their information:
Name______________________________________________________Title____________________________________
Address____________________________________________ Telephone ( ) _________________________
City/ZIP____________________________________________________________________________________________
If you need special help due to a disability, please contact the Division of Hearings at the numbers listed below.
Mail this request to: DTA, P.O. Box 4017, Taunton MA 02780‐0314 or fax (both sides) to (617) 348‐5311.
If you are currently getting cash benefits – If we get this request before the date your benefits are to be stopped or lowered,
your benefits will continue until the appeal is decided. If you lose your appeal, you will have to pay back these benefits. If you
get TAFDC time limited benefits during your appeal and you lose, the months of benefits you received may count toward your
time limit.
If you are currently getting SNAP benefits ‐‐ If we get this request before your benefits are lowered or stopped, your benefits
will continue until the appeal is decided, or your SNAP certification period ends, whichever comes first. If you lose your SNAP
appeal, you will have to pay back the benefits you received during your appeal.
If you do not want to get benefits during your appeal ‐ Check this box
. If you choose not to get benefits during the appeal
period, and win your appeal, DTA will pay you any benefits owed.
What are the deadlines for appealing? We must get your appeal request no later than 90 days from the date the Department
sent you written notice of the action you are appealing.
But there are exceptions:
There is no deadline if you appeal the amount of your SNAP benefits during your certification period.
You have 120 days if DTA fails to act on your request for benefits or services.
You generally have 120 days if the appeal is about coercive or improper conduct by a DTA employee.
You only have 30 days if you are appealing because your state tax refund has been held to repay an overpayment of
DTA benefits.
Do you need an interpreter? – You have the right to a free interpreter if you need one. The interpreter will keep all of the
information about your case confidential. You also have the right to bring your own interpreter. If you need an interpreter,
please call us at any of the phone numbers listed in the section below or check this box
and tell us your primary language or
dialect:________________________________________ and we will provide an interpreter for you.
What if I cannot come on the date of the hearing? If you need to reschedule, please call at (617) 348‐5321 or (800) 882‐2017
at least one day before the hearing. If you do not reschedule and miss the hearing, we will send you a letter about your rights.
If you had a good reason for missing the hearing, we may be able to give you a new hearing.
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DOH‐10 (Rev.12/2015)
02‐148‐1215‐05
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