Iowa Department of Human Services

Appeal and Request for Hearing

Fill out the top part of this form.  You do not need to fill out the worker information part.


Appellant Information (Please Print) Check the programs you want to appeal.

Family Investment Program (FIP), 

      Refugee Cash Assistance (RCA)  

      or PROMISE JOBS

Child Care Assistance

Food Assistance

Medicaid or Waiver

Attribution

Administrative Hearing (only for 

      attribution appeals)

State Supplementary Assistance

Child Support

  Adoption or Foster Care

  Other (explain):

 

Name:  Last

First

MI

Mailing Address:

City

State

Zip Code

Phone Number

County

I want my benefits to continue, if they can.        Yes   No     You may have to pay them back if you lose your appeal.

I want an interpreter for my hearing.                Yes   No     We will provide an interpreter for you.

I want a pre-hearing conference.                     Yes   No

Tell us why you are appealing.  Please be brief.

Your Signature                                                                                 Date

                

 

If 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

         

Mailing Address

City                                        State                          Zip Code

 Worker Information                                                                                               

Worker Name

Phone Number

Worker Number

County/Office

Case Number/SID Number

Will benefits continue or did you reinstate benefits because of this appeal?  Yes  No

If not, why                                                                      If other, explain

         

If the consumer says they need an interpreter, what language do they need? 
The adverse action appealed is the result of a:
DDS report               IFMC decision
LBP                        PJ worker Office
Q.C. report              QC worker Office
DIA Investigation      Investigator Office
Attach a copy of the NOD being appealed.  If it isn't attached, explain why:
Tell us your vacation and training schedule for the next 3 months.
470-0487 (Rev. 7/05)