Form Temp 2172 - Notice Of Action Page 2
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1
2TO 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 or
•
Send or take this page to:
mailed you this notice.
If you ask for a hearing before an action on Cash Aid,
Medi-Cal, Food Stamps, or Child Care takes place:
•
Your Cash Aid or Medi-Cal will stay the same while you wait for a
OR
hearing.
•
Call toll free: 1-800-952-5253 or for hearing or speech impaired
who use TDD, 1-800-952-8349.
•
Your Child Care Services may stay the same while you wait for a
hearing.
To Get Help: You can ask about your hearing rights or for a legal
•
Your Food Stamps will stay the same until the hearing or the end
aid referral at the toll-free state phone numbers listed above. You
of your certification period, whichever is earlier.
may get free legal help at your local legal aid or welfare rights office.
If the hearing decision says we are right, you will owe us for any
extra Cash Aid, Food Stamps or Child Care Services you got.
To let us lower or stop your benefits before the hearing, check below:
Yes, lower or stop:
Cash Aid
Food Stamps
Child Care
If you do not want to go to the hearing alone, you can bring a
While You Wait for a Hearing Decision for:
friend or someone with you.
Welfare to Work:
HEARING REQUEST
You do not have to take part in the activities.
I want a hearing due to an action by the Welfare Department
of ________________________________ County about my:
You may receive child care payments for employment and for
!
!
!
activities approved by the county before this notice.
Cash Aid
Food Stamps
Medi-Cal
!
If we told you your other supportive services payments will stop, you
Other (list)___________________________________________
will not get any more payments, even if you go to your activity.
Here's Why: ____________________________________________
If we told you we will pay your other supportive services, they will be
paid in the amount and in the way we told you in this notice.
_______________________________________________________
•
To get those supportive services, you must go to the activity the
_______________________________________________________
county told you to attend.
•
If the amount of supportive services the county pays while you
_______________________________________________________
wait for a hearing decision is not enough to allow you to
_______________________________________________________
participate, you can stop going to the activity.
Cal-Learn:
_______________________________________________________
•
You cannot participate in the Cal-Learn Program if we told you
!
If you need more space, check here and add a page.
we cannot serve you.
!
I need the state to provide me with an interpreter at no cost to me.
•
We will only pay for Cal-Learn supportive services for an
(A relative or friend cannot interpret for you at the hearing.)
approved activity.
My language or dialect is: ____________________________
OTHER INFORMATION
NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
Medi-Cal Managed Care Plan Members: The action on this notice may stop
you from getting services from your managed care health plan. You may wish
BIRTH DATE
PHONE NUMBER
to contact your health plan membership services if you have questions.
STREET ADDRESS
Child and/or Medical Support: The local child support agency will help
collect support at no cost even if you are not on cash aid. If they now collect
CITY
STATE
ZIP CODE
support for you, they will keep doing so unless you tell them in writing to stop.
They will send you current support money collected but will keep past due
SIGNATURE
DATE
money collected that is owed to the county.
Family Planning: Your welfare office will give you information when you ask
NAME OF PERSON COMPLETING THIS FORM
PHONE NUMBER
for it.
!
I want the person named below to represent me at this
Hearing File: If you ask for a hearing, the State Hearing Division will set up a
file. You have the right to see this file before your hearing and to get a copy of
hearing. I give my permission for this person to see my
the county's written position on your case at least two days before the hearing.
records or go to the hearing for me. (This person can be a
The state may give your hearing file to the Welfare Department and the U.S.
friend or relative but cannot interpret for you.)
Departments of Health and Human Services and Agriculture.
(W&I Code
Sections 10850 and 10950.)
NAME
PHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
NA BACK 9 (REPLACES NA BACK 8 AND EP 5) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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