Form Ssp 17 - Notice Of Action And Right To Request A State Hearing On Interim Assistance Page 2
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1
2YOUR HEARING RIGHTS
HOW TO ASK FOR A STATE HEARING
To Ask For a State Hearing
The best way to ask for a hearing is to fill out this page and
send or take it to :
The right side of this sheet tells how.
•
You only have 90 days to ask for a hearing.
•
The 90 days started the day after we mailed this notice.
To Get Help
You can ask about your hearing rights or free legal aid at the
You may also call 1-800-952-5253.
state information number.
Call toll free:
1-800-952-5253
HEARING REQUEST
If you are deaf and use TDD call:
1-800-952-8349
I want a hearing because of an action by_____________________
If you don't want to come to the hearing alone, you can bring a
about the interim assistance said department deducted from my
friend, an attorney or anyone else. You must get the other person
SSI/SSP payment.
yourself.
Here's why: _________________________________________
You may get free legal help at your local legal aid office of welfare
rights group.
______________________________________________________
Other Information
______________________________________________________
The information you provide on this form is needed to process your
______________________________________________________
request for a hearing, and processing may be delayed if your request
is incomplete. A case file will be set up by the State Hearing Officer.
______________________________________________________
You have a right to examine the materials that make up the file. Any
information you provide may be shared with the departments whose
action you are appealing and the U.S. Department of Health and
______________________________________________________
Human Services. Authority: W&IC 10950.
______________________________________________________
______________________________________________________
I will bring this person to the hearing to help me
(name and address, if known):
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
I need an interpreter at no cost
to me. My language or dialect is: ___________________________
______________________________________________________
My name:
_________________________________________
______________________________________________________
Address:
_________________________________________
______________________________________________________
_________________________________________
______________________________________________________
Phone:
_________________________________________
______________________________________________________
My signature:
_________________________________________
______________________________________________________
Date:
_________________________________________
______________________________________________________
SSP 17 (back)
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