Instructions

Use of this form is not mandatory.  Any written appeal is a valid appeal.

Verbal appeals are valid only in the Food Assistance program.  The worker receiving the Food Assistance appeal should record verbal appeals on this form.  Be sure to indicate that this is a verbal appeal.

If you get a letter stating the consumer wants to appeal, attach the letter to this form.  You need to fill in the consumer's information and your information.

If you do not know what the consumer is appealing, you need to indicate what you think the appeal is about.  The DHS Appeals Section will ask the consumer for additional information, if necessary.  Do not hold an appeal if you need to get additional information from the consumer.

On the front of this form, date-stamp all appeals on the date they are received in your office.  If you got the appeal in the mail, keep the postmarked envelope and attach it to this form.

Attach a copy of the Notice of Decision that the consumer appealed to this form.  Send this to:

Department of Human Services
Appeals Section, 5th Floor
1305 E Walnut St
Des Moines, IA  50319-0114

Send in an appeal summary to the DHS Appeals Section within 10 calendar days of the date the appeal was filed.  Do not delay sending in an appeal while you work on your appeal summary.

Send all new appeals to the DHS Appeals Section within one working day of receipt.  Be sure to include the Notice of Decision and the postmarked envelope, if applicable.  Use local mail if available.

Be sure to indicate your vacation and training schedule for the next 3 months.  This will be used when scheduling a hearing.

For more information about appeals, check out the Appeals Section intranet site at http://intranet01/appeals/

470-0487 (Rev. 7/05)    Back to Appeals Page