Department of Human Services
and Request for Hearing
out the top part of this form. You do not need to fill out the worker
Family Investment Program
Refugee Cash Assistance (RCA)
or PROMISE JOBS
Child Care Assistance
Medicaid or Waiver
Administrative Hearing (only for
State Supplementary Assistance
Adoption or Foster Care
want my benefits to continue, if they can.
You may have to pay them back if you lose your appeal.
want an interpreter for my
No We will provide an interpreter for you.
want a pre-hearing
us why you are appealing. Please be brief.
you want someone to help you with your appeal, please write the
person's name and address below. This person get information
about your appeal. You are not required to list someone here.
Name Phone Number
Case Number/SID Number
benefits continue or did you reinstate benefits because of this
If other, explain
Appellant chose not to have benefits continue
Appeal not filed before the effective date