Fair Hearing Form printable pdf download

FAIR HEARING INFORMATION – Food Stamps, G.A., TANF, Emergency Assistance

REQUEST FOR A HEARING: IF YOU ARE A WFNJ/TANF OR GA CLIENT YOU HAVE A RIGHT TO REQUEST A FAIR

HEARING ON ANY ADVERSE ACTION WITHIN 90 DAYS. IF THE ACTION TAKEN ON YOUR PUBLIC ASSISTANCE

CASE IS DUE TO A CHANGE IN PUBLIC LAW, A HEARING WILL NOT BE GRANTED UNLESS THE REASON FOR THE

REQUEST IS DUE TO AN INCORRECT GRANT COMPUTATION.

CONTINUED, UNREDUCED ASSISTANCE: YOUR WFNJ/TANF OR WFNJ/GA BENEFIT WILL NOT BE TERMINATED

OR REDUCED IF YOU REQUEST A HEARING WITHIN 15 DAYS OF THE MAILING DATE OF THE AGENCY’S ADVERSE

ACTION NOTICE. HOWEVER THOSE UNREDUCED BENEFITS WILL HAVE TO BE REPAID IF THE FINAL HEARING

DECISION SUPPORTS THE COUNTY WELFARE AGENCY. FOOD STAMP BENEFITS WILL NOT BE CHANGED UNTIL

THE END OF THE CERTIFICATION PERIOD, IF APPLICABLE. YOU MAY ELECT TO NOT RECEIVE CONTINUED

ASSISTANCE.

YOUR RIGHTS: CONCERNING THE HEARING, YOU WILL HAVE A RIGHT TO:

•

PRESENT YOUR OWN CASE OR HAVE A FRIEND, RELATIVE OR ATTORNEY MAKE THE PRESENTATION.

•

SUBMIT ANY EVIDENCE AND/OR BRING ANY WITNESSES THAT BEAR ON YOUR CASE.

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QUESTION OR CHALLENGE ANY WITNESS OR EVIDENCE PRESENTED BY THE COUNTY AGENCY.

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EXAMINE RECORDS OR CASE FILE, INCLUDING THE APPLICATION FORM. YOU MAY ALSO EXAMINE THE

CASE RECORDS IN ADVANCE, (EXCEPT FOR CONFIDENTIAL RECORDS WHICH ARE PROTECTED FROM

RELEASE AND WHICH MAY NOT BE INTRODUCED BY THE AGENCY AS EVIDENCE).

•

REVIEW A COMPLETE AND UP-TO-DATE COPY OF THE FOOD STAMP OR PUBLIC ASSISTANCE MANUALS.

HOW TO REQUEST A HEARING: IF YOU WlSH TO REQUEST A HEARING, YOU MAY TELEPHONE, WRITE, COME TO

THE COUNTY WELFARE AGENCY, OR USE THE FORM BELOW.

LEGAL SERVICES: LEGAL SERVICES ARE PRIVATE, NON-PROFIT ORGANIZATIONS THAT ARE NOT CONNECTED

IN ANY WAY WITH ANY LOCAL OR COUNTY WELFARE AGENCY OR ANY OTHER GOVERNMENT AGENCIES AND

THEY PROVIDE FREE LEGAL SERVICES TO ELIGIBLE PEOPLE IN MOST CIVIL MATTERS. CONTACT INFORMATION:

NORTHEAST NJ LEGAL SERVICES, 61 KANSAS STREET, HACKENSACK, NJ 07601-5351, (201) 487-2166.

IF YOU WISH FURTHER INFORMATION ON THE FAIR HEARING PROCESS, YOU MAY CALL THE STATE TOLL-FREE

HOTLINE NUMBER 800-792-9773 OR CONTACT YOUR COUNTY WELFARE AGENCY WORKER.

CLIENT NOTIFICATION OF NON-DISCRIMINATION POLICY: TITLE VI OF THE CIVIL RIGHTS ACT 0F 1964, AS

AMENDED; SECTION 504 OF THE REHABILITATION ACT OF 1973; AGE DISCRIMINATION ACT OF 1975, AND THE

AMERICANS WITH DISABILITIES ACT OF 1990 PROHIBIT DISCRIMINATION ON THE BASIS OF RACE, AGE, COLOR,

NATIONAL ORIGIN, AND/OR DISABILITY IN ANY PROGRAM RECEIVING FEDERAL FUNDS. SPECIFICALLY, THE

FOLLOWING PROGRAMS ALSO PROHIBIT DISCRIMINATION:

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WORK FIRST NEW JERSEY/TEMPORARY ASSISTANCE FOR NEEDY FAMILIES PROGRAM OR WFNJ/GA:

THESE PROGRAMS PROHIBIT DISCRIMINATION IN DETERMINING ELIGIBILITY FOR PUBLIC ASSISTANCE.

IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST BECAUSE OF RACE, COLOR, AGE,

DISABILITY, RELIGION, NATIONAL ORIGIN, WRITE IMMEDIATELY TO THE FOLLOWING: U.S. DEPARTMENT

OF HEALTH AND HUMAN SERVICES, OFFICES OF CIVIL RIGHTS, FEDERAL BUILDING, 25 FEDERAL PLAZA,

NEW YORK, NY 10007, OR OFFICE OF THE DIRECTOR, DIVISION OF FAMILY DEVELOPMENT, N.J.

DEPARTMENT OF HUMAN SERVICES, P.O. BOX 7I6, TRENTON N.J. 08625.

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FOOD STAMP PROGRAM: THIS IS AN EQUAL OPPORTUNITY PROGRAM. IF YOU BELIEVE YOU HAVE

BEEN DISCRIMINATED AGAINST BECAUSE OF RACE, COLOR, NATIONAL ORIGIN, AGE, SEX, DISABILITY,

POLITICAL BELIEFS OR RELIGIOUS CREED, WRITE IMMEDIATELY TO THE FOLLOWING: SECRETARY OF

AGRICULTURE, WASHINGT0N, D.C., 20250, OR OFFICE OF THE DIRECTOR, DIVISION OF FAMILY

DEVELOPMENT, N.J. DEPARTMENT OF HUMAN SERVICES, P.O. BOX 7I6, TRENTON, N.J. 08625.

FAIR HEARING REQUEST: COMPLETE ALL INFORMATION

Case # _____________________

CHECK OFF:

-EMER. ASSIST.

-TANF

-GA

-FOOD STAMPS

-OTHER (Explain)________________________

DATE OF ADVERSE ACTION NOTICE ______________ WHAT ACTION TOOK PLACE AND WHY DO YOU DISAGREE?

___________________________________________________________________________________________________

__________________________________________________________________ ATTACH ADDITIONAL INFORMATION

-I WISH TO CONTINUE RECEIVING ASST. UNTIL THE HEARING

-I DO NOT WISH TO CONTINUE RECEIVING

ASST. UNTIL THE HEARING.

NAME ___________________________________________ ADDRESS________________________________________

SIGNATURE______________________________________

________________________________________

DATE____________________________________________ TEL #____________________________________________

Fair Hearing Form

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