DHS-0035-ENG (State Agency Appeals Summary)

Appellant Information

JUDGE'S NAME

DOCKET NUMBER

APPELLANT'S FIRST NAME

APPELLANT'S LAST NAME

PHONE NUMBER

STREET ADDRESS 1

STREET ADDRESS 2

CITY

STATE

ZIP CODE

APPELLANT'S CASE NUMBER

PMI

SERVICING COUNTY

COUNTY FINANCIAL RESPONSIBILITY

Does appellant need an interpreter for the hearing?

Yes

What is their preferred language?

Representative or Advocate

Does appellant have a representative or advocate?

Yes

REPRESENTATIVE OR ADVOCATE NAME

PHONE NUMBER

STREET ADDRESS 1

STREET ADDRESS 2

CITY

STATE

ZIP CODE

REPRESENTATIVE OR ADVOCATE RELATIONSHIP TO APPELLANT

Action taken

Check all applicable actions.

Denial

Termination

Reduction

Suspension

Overpayment

Other

Denial notice of action date

Denial date appeal first received by County or State Agency

Termination notice of action date

Termination date appeal first received by County or State Agency

Reduction notice of action date

Reduction date appeal first received by County or State Agency

Suspension notice of action date

Suspension date appeal first received by County or State Agency

Overpayment notice of action date

Overpayment date appeal first received by County or State Agency

Other notice of action date

Other date appeal first received by County or State Agency

Describe other action

Are benefits/services continuing pending appeal?

Yes

Authority for action

Cite applicable federal regulation, state statute, rule or program manual section relied upon.

Appeal issues

Briefly summarize the facts and the reason the agency made its decision. Agencies may also attach a more detailed explanation on the Attachments page.

Attachments

Attach copies of: Full narrative of agency decision, Notice of Action/Grant Calculation, Appellant's Request for Appeal(s), relevant statutory, rule, or manual provisions, and other relevant documents. This may include a detailed summary, the notice of action, grant calculation, overpayment worksheet, appellant's appeal request, case notes, verification requests and submissions, paystubs/wage matches, investigative reports, relevant authority, recorded interviews, program policy or other relevant documents. If the appeal is brought by a person with a developmental disability subject to a conciliation conference, attach the conciliation conference report. If possible, number the pages of your submission so that it is easier for participants to follow during the hearing. Send the appellant and their representatives anything that is submitted here.

You may attach multiple files. Your total submission size (all attachments combined) cannot be larger than 500 MB. Attempts to make a submission larger than 500 MB will not be successful.

Acceptable files types are: Adobe PDF Portfolios, doc, docm, docx, dotx, gif, jpg, jpeg, m4a, mov, mp3, mp4, mpeg, m4v, pdf, png, tif, txt, wav, wma, wmv, xlsm, xls, xlsx, and zip.

Contact the Appeals Division at 651-431-3600 if you have a file type that is not included in the list of acceptable file types.

Note: if you use the “Save and continue later” function, do not upload as attachments will not be saved with the form.

Hearing Attendees

Will the agency be attending the hearing?

Yes

List the Agency Representatives' contact information.

Click the + icon to add an attendee

Hearing Attendee

AGENCY REPRESENTATIVE

PHONE NUMBER FOR HEARING

AGENCY REPRESENTATIVE'S EMAIL

Save or Submit

AGENCY REPRESENTATIVE

PHONE NUMBER FOR HEARING

TITLE

AGENCY REPRESENTATIVE'S EMAIL

CONFIRM AGENCY REPRESENTATIVE'S EMAIL

TODAY'S DATE

After clicking the submit button, you will receive confirmation that your form and document(s) were submitted if your attempt was successful. If you do not receive the confirmation, your submission is too big and was not received. You will need to resubmit the document(s) using multiple submissions of smaller file sizes.

If you used the “Save and continue later” function, remember to upload your attachments before submitting.

State law requires the agency whose action is being appealed to mail or otherwise deliver a completed appeal summary to the appellant and Appeals Division at least three working days before the hearing. By submitting this form to the Appeals Division, you will not have satisfied the requirement to provide to the appellant a completed appeal summary – you must separately send the completed summary to the appellant by some other means. The Appeals Division is not responsible for providing the completed summary to the appellant and will not provide the completed summary to the appellant.

State Agency Appeals Summary