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Form Na 1261b - Notice Of Action - Form And Instructions - For Kinship-Guardians Only Page 2

TO ASK FOR A HEARING:

YOUR HEARING RIGHTS

•

Fill out this page.

You have the right to ask for a hearing if you disagree with

•

Make a copy of the front and back of this page for your records.

any county action. You have only 90 days to ask for a

If you ask, your worker will get you a copy of this page.

hearing. The 90 days started the day after the county gave

•

Send or take this page to:

or mailed you this notice.

•

Call toll free: 1-800-952-5253 or for hearing or speech impaired

who use TDD, 1-800-952-8349.

To Get Help: You can ask about your hearing rights or for a legal

aid referral at the toll-free state phone numbers listed above. You

may get free legal help at your local legal aid or welfare rights office.

If you do not want to go to the hearing alone, you can bring a

friend or someone with you.

HEARING REQUEST

I want a hearing due to an action by the Welfare Department

of ________________________________ County about my:

Overpayment ________________________________________

Here's Why: ____________________________________________

_______________________________________________________

If you need more space, check here and add a page.

I need the state to provide me with an interpreter at no cost to me.

(A relative or friend cannot interpret for you at the hearing.)

My language or dialect is: ____________________________

NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED

BIRTH DATE

PHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

SIGNATURE

DATE

NAME OF PERSON COMPLETING THIS FORM

PHONE NUMBER

I want the person named below to represent me at this

hearing. I give my permission for this person to see my

records or go to the hearing for me. (This person can be a

friend or relative but cannot interpret for you.)

NAME

PHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

NA 1261B BACK (1/16)

Form Na 1261b - Notice Of Action - Form And Instructions - For Kinship-Guardians Only Page 2

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