Form Na 1261 - Notice Of Action - Form And Instructions - For Group Homes, Short-Term Residential Treatment Centers, Foster Family Agencies, Transitional Housing Placement-Plus Foster Care And Transitional Housing Placement Program Page 2
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1
2YOUR HEARING RIGHTS
TO ASK FOR A HEARING:
You have the right to ask for a hearing if you disagree with
•
Fill out this page.
•
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 or
•
Send or take this page to:
mailed you this notice.
State Hearing: If you think this action is wrong, you can ask for a
hearing. Your benefits may not be changed if you ask for a hearing
before this action takes place.
OR
•
Call toll free: 1-800-952-5253 or for hearing or speech impaired
who use TDD, 1-800-952-8349.
To request a Hearing:
If you think this action is wrong, you can ask for either an informal
To Get Help: You can ask about your hearing rights or for a legal
hearing provided by the County or a formal State hearing. Your
aid referral at the toll-free state phone numbers listed above. You
benefits may not be changed if you ask for a hearing before this action
may get free legal help at your local legal aid or welfare rights office.
takes place.
In order to request an informal hearing, your request must be made no
later than 30 calendar days after this notice was mailed to you. You
may send your request by any of the following methods.
If you do not want to go to the hearing alone, you can bring a
friend or someone with you.
In writing:
Email requests:
HEARING REQUEST
I want a hearing due to an action by the Welfare Department
of ________________________________ County about my:
n
Phone requests:
Overpayment ________________________________________
Address
Here's Why: ____________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Your request should state why you want the informal hearing and if
_______________________________________________________
you will need a free interpreter. If so, please indicate what language
_______________________________________________________
or dialect you speak.
n
If you need more space, check here and add a page.
n
You may appeal the informal hearing decision at a formal State
I need the state to provide me with an interpreter at no cost to me.
hearing. You may request the formal State hearing within 90 calendar
(A relative or friend cannot interpret for you at the hearing.)
days after the informal hearing decision is mailed to you. If the
informal hearing is requested but not held, the 90 days will begin 31
My language or dialect is: ____________________________
calendar days from the date of this notice.
NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
BIRTH DATE
PHONE NUMBER
If you choose a formal State hearing, please note that you must
request that State hearing within 90 calendar days of the receipt
STREET ADDRESS
of this notice.
CITY
STATE
ZIP CODE
If you have any questions, contact the worker at the top of the first
SIGNATURE
DATE
page of this form.
NAME OF PERSON COMPLETING THIS FORM
PHONE NUMBER
n
TDD - For Hearing Impaired
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 1261 BACK (1/16)
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