Form Na 801 - Notice Of Action Gain (Manual Process) Page 2
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1
2HOW TO ASK FOR A STATE HEARING
YOUR HEARING RIGHTS
To Ask For a State Hearing
The best way to ask for a hearing is to fill out this page. Make
a copy of the front and back for your records. Then, send or
•
You only have 90 days to ask for a hearing. The 90
take this page to:
days started the day after we gave or mailed you this
notice.
•
You have a much shorter time to ask for a hearing if
you want to keep your same benefits.
To Keep Your Same Benefits While You Wait For a Hearing
Your worker will get you a copy of this page if you ask. Another
way to ask for a hearing is to call 1-800-952-5253. If you are
You must ask for a hearing before the action takes place.
deaf and use TDD, call: 1-800-952-8349.
•
Your Cash Aid will stay the same until your hearing.
HEARING REQUEST
•
Your Medi-Cal will stay the same until your hearing.
I want a hearing because of an action by the Welfare Department
•
Your Food Stamps will stay the same until the hearing
or the end of your certification period, whichever is
of _____________________________________ County about my
earlier.
Cash Aid
Food Stamps
Medi-Cal
Child Care
•
Your CalWORKs Child Care benefits will NOT stay the
same until your hearing.
Other (list) _________________________________________
•
If the hearing decision says we are right, you will owe
Here's why:___________________________________________
us for any extra cash aid or food stamps you got.
_____________________________________________________
To Have Your Benefits Cut Now
_____________________________________________________
If you want your Cash Aid or Food Stamps cut while
you wait for a hearing, check one or both boxes.
_____________________________________________________
Cash Aid
Food Stamps
_____________________________________________________
To Get Help
_____________________________________________________
You can ask about your hearing rights or free legal aid at
_____________________________________________________
the state information number.
Call toll free:
1-800-952-5253
_____________________________________________________
If you are deaf and use TDD, call: 1-800-952-8349
_____________________________________________________
You may get free legal help at your local legal aid office or
_____________________________________________________
welfare rights group.
_____________________________________________________
_____________________________________________________
_____________________________________________________
Check here and add a page if you need more space.
I want the person named below to represent me at this hearing.
I give my permission for this person to see my records or come
Other Information
to the hearing for me.
Child and/or Medical Support: The District Attorney’s office will help
NAME________________________________________________
you collect support even if you are not on cash aid. There is no cost for
this help. If they now collect support for you, they will keep doing so
ADDRESS ____________________________________________
unless you tell them in writing to stop. They will send you any current
support money collected. They will keep past due money collected that
____________________________________________
is owed to the county.
I need a free interpreter.
Your welfare office will give you information
Family Planning:
My language or dialect is: _____________________________
when you ask for it.
Hearing File: If you ask for a hearing, the State Hearing Office will set
My name:
_________________________________________
up a file. You have the right to see this file. The State may give your file
to the Welfare Department, the U.S. Department of Health and Human
Address:
_________________________________________
Services and the U.S. Department of Agriculture. (W. & I. Code Section
10950).
_________________________________________
Phone:
_________________________________________
My case number:_______________________________________
My signature: _________________________________________
Date:
_________________________________________
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Parent category: Legal