Form Na 692 - Notice Of Change - Cash Assistance Program For Immigrants (Capi) Page 4
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4TO ASK FOR A HEARING:
• Fill out this page.
• Make a copy of the front and back of this page for your records. If you ask, your worker will get you a
copy of this page.
• Send or take this page to:
OR
• 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:
Cash Aid
CalFresh
Medi-Cal
Other (list) ____________________________________________
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 BACK 9 (Replaces NA BACK 8 And EP 5) (12/17)
Page 2 of 2
Required Form – No Substitute Permitted
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