Form Hrp-1032a - Commodity Senior Food Program (Csfp) Informal Dispute Resolution Meeting / Fair Hearing Request

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CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1032A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
INFORMAL DISPUTE RESOLUTION MEETING / FAIR HEARING REQUEST
CLIENT INFORMATION
CLIENT NAME
DATE OF BIRTH
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NUMBER
DISTRIBUTION SITE NAME
DISTRIBUTION SITE ADDRESS
CITY
STATE
ZIP CODE
Check the appropriate box to request a fair hearing or informal dispute resolution meeting, then complete the remainder
of the form.
I want a FAIR HEARING for CSFP
I want an INFORMAL DISPUTE RESOLUTION MEETING for CSFP
I am making this request because I do not agree with:
Discontinuance of Benefits  
Denial of Application
Overpayment or Disqualification
Other (explain):
I disagree with the decision for the following reason(s):
Date of the notice I do not agree with:
I need an interpreter:
Yes
No
If yes, what language?
IMPORTANT: Read your fair hearing rights on the back of this form before filling out this section.
I DO want to keep getting benefits during my fair hearing (fair hearing requests only).
I DO NOT want to keep getting benefits during my fair hearing (fair hearing requests only).
CLIENT/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
See reverse for USDA nondiscrimination and EOE/ADA/LEP/GINA statements

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