Form Rfa 09e - Notice Of Action And Exclusion Order Page 3
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5State of California – Health and Human Services Agency
California Department of Social Services
If you wish to appeal this exclusion order you may do so by submitting a written appeal and a copy of this
notice to the address below. The appeal must be post marked or delivered on or before the due date,
which is twenty-five (25) calendar days from the date of this notice. Add five (5) days to the due date for a
total of 30 calendar days if this notice was mailed to you. The appeal must be post marked or delivered on or
before the due date. If you wish to use this form to appeal, you may do so by checking the box and filling out
the information below. Send the appeal and all pages of this notice to:
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
[DEPARTMENT ADDRESS, MS -
CITY, STATE, ZIP
ATTN: Contact Name, Title]
Effective Date of Order:
If you file your appeal to this exclusion order on or before the due date, this exclusion order will not be effective
until completion of the administrative review process and the effective date of a decision and order by the
department upholding this exclusion order. The Department will send you an acknowledgment of your appeal
and you will be contacted and provided additional information about the appeal process at a later date. If you
appeal, it is required that you notify the Department in writing at the address listed above of your current
address and any subsequent change in your mailing address, until the administrative review process has been
completed or terminated.
If you do not appeal this exclusion order on or before the due date, the Exclusion Order will be final and shall
be effective on:
On this date you will be excluded from all resource family homes and all facilities licensed by the Department
[Insert Date one day after appeal is due (Day 26 for personal service or Day 31 for mail).]
or certified or approved by a Foster Family Agency, for the remainder of your life. However, you may petition
for reinstatement to the Department one year after the effective date of the final exclusion order pursuant to
Government Code Section 11522 (attached).
You may call the Department at
if you have any questions regarding this notice.
________________________________________________
[Sign Above, Type In Name & Title]
I wish to appeal. (Submit this appeal request with a copy of this notice.)
________________________________________________
_____________________________
Print Name
Signature
________________________________________________
_____________________________
Address
Phone Number
Reasons for appeal (optional): _______________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
RFA 09E (9/17) Non-Immediate (To individual)
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