Dss Form 2633 - Request For Fair Hearing
ADVERTISEMENT
1
2South Carolina Department of Social Services
REQUEST FOR FAIR HEARING
A signed letter from the client requesting a fair hearing may be attached instead of this signed form.
To be completed by county worker or client:
Client’s Name:
Case Number:
Client’s Address:
County:
County Worker’s Name:
Program:
n
n
Client’s Telephone:
FI
JUMMP
n
n
Client’s Representative and Address:
Adoptions
SNAP
(If any)
n
n
Child Protective Services
E&T
n
n
ABC
Licensing
n
n
Child and Adult Care Food Program
Foster Care
n
Other:
Notice Sent on:
When was the client notified of the action he/she
Effective Date:
wishes to appeal?
If you need any of the following accommodations, please ask for them. They will be furnished at no cost.
n
n
n
Interpreter
Documents Translated
Special Accommodations
What language?
What accommodations?
I request a fair hearing from the South Carolina Department of Social Services because:
n
Action has not been taken on my application within a timely manner.
n
My application has been turned down.
n
My check/service has been stopped.
n
My check/service has been reduced or changed.
n
I have been charged with an overissuance or overpayment.
n
My EBT account has been incorrectly adjusted due to a system error.
n
Other:
(Explain. Attach a sheet, if additional space is needed.)
In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services
(HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under
the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.
To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Adjudication, 1400 Independence Avenue,
SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech
disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). Write HHS,
Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice)
or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.
You may also file a complaint of discrimination by contacting DSS. Write DSS Office of Civil Rights, P.O. Box 1520, Columbia, SC
29202-1520; or call 1-800-311-7220 or (803) 898-8080, TTY: 1-800-311-7219.
DSS Form 2633 (SEP 14) Edition of AUG 14 is obsolete.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal