Summary. Eighteen templates, in case order.
1. Expedited service request
Say this at the counter, on the phone, or write it on the application.
REQUEST FOR EXPEDITED SERVICE
Applicant: ______________ Date of application: ____/____/______
I am requesting expedited service. I believe I qualify because:
[ ] My household's monthly gross income is $______ and our available
liquid resources (cash, checking, savings) total $______. Both are
below the expedited thresholds.
[ ] My household's combined monthly gross income ($______) plus liquid
resources ($______) = $______, which is LESS than our monthly rent
or mortgage ($______) plus utilities ($______) = $______.
[ ] My household is a destitute migrant or seasonal farmworker
household.
CURRENT SITUATION
There is [no food / less than __ days of food] in my home today.
Household members: ______ adults, ______ children (ages ______).
I understand that for expedited cases, verification is generally limited
to identity, with other verification postponed. I am providing
identification today and request a determination without being required
to return with additional documents first.
I can be reached at [phone] today and every day.
______________________ Date: ________
FOR THE FILE: I gave this request to ______________ at ______ on ________
and received [a date-stamped copy / confirmation number ____________].
2. Separate household statement
The single most valuable one-page document in an eligibility dispute.
STATEMENT REGARDING HOUSEHOLD COMPOSITION
Case/application number: ______________
Address: ______________________________
I live at the above address with the following people:
NAME RELATIONSHIP TO ME IN MY HOUSEHOLD?
____________________ __________________ Yes / NO
____________________ __________________ Yes / NO
____________________ __________________ Yes / NO
MY HOUSEHOLD consists of: ______________________________________
The following people live at this address but are NOT part of my
household because we do not purchase and prepare meals together:
[Name], who is my [roommate / boarder / live-in attendant].
HOW WE ACTUALLY LIVE:
- We shop separately. I buy my food at ______________; [Name] buys
[his/her/their] food separately.
- We store food separately. [Describe: separate shelves, separate
refrigerator space, a separate refrigerator.]
- We cook separately and eat separately.
- We do not pool money for food.
- [If a boarder: [Name] pays me $______ per month for lodging and
meals.]
- [If an attendant: [Name] is employed as my personal care attendant
and is compensated by ______________.]
I understand that spouses, and parents living with their children under
22, must be in the same household regardless of how food is purchased,
and that this does not apply here because ______________________.
ATTACHED PROOF
[ ] Separate grocery receipts (mine and [Name]'s, same week)
[ ] Signed statement from [Name]
[ ] Photographs of separate food storage
[ ] Sublease or written rent arrangement
[ ] Separate utility accounts, if any
I declare that the above is true and correct.
______________________ Date: ________
Companion statement for the other person:
STATEMENT OF [NAME]
I live at [address] with [Applicant]. I am [his/her/their]
[roommate / boarder / attendant].
I purchase my own food separately from [Applicant]. I store it
[describe]. I prepare and eat my meals separately. We do not pool money
for food or share meals as a household.
[If paying rent: I pay $______ per month to [Applicant] for my room.]
I declare that this is true and correct.
______________________ · [Phone] Date: ________
[Attach a copy of photo identification.]
3. Medical expense worksheet
For households with an elderly or disabled member. This is the most valuable unclaimed deduction in the program.
MEDICAL EXPENSE DEDUCTION WORKSHEET
Household member who is elderly (60+) or disabled: ______________
Basis: [ ] age 60 or older [ ] receives SSI/SSDI [ ] receives
disability-based benefits [ ] other: ______________
MONTHLY OR RECURRING COSTS
Prescription medications $ ________
Over-the-counter medicine approved by a
practitioner $ ________
HEALTH INSURANCE PREMIUMS
Medicare Part B (deducted from Social
Security check — CHECK THE AWARD LETTER) $ ________
Medicare Part D $ ________
Supplemental / Medigap policy $ ________
Other health insurance $ ________
Medicare deductibles and copayments $ ________
Medical supplies (test strips, lancets,
catheters, ostomy, incontinence supplies) $ ________
Durable equipment (walker, wheelchair, CPAP,
oxygen, hospital bed) — purchase or rental $ ________
Attendant, homemaker, or home health aide $ ________
SERVICE ANIMAL — food, veterinary care,
supplies $ ________
Nursing home or hospital care $ ________
ANNUAL OR OCCASIONAL COSTS (enter annual, divide by 12)
Eyeglasses / contacts $______ /12 = $ ________
Hearing aids and batteries $______ /12 = $ ________
Dentures and dental work $______ /12 = $ ________
Prosthetics / orthotics $______ /12 = $ ________
Doctor, dentist, hospital,
clinic bills paid $______ /12 = $ ________
Surgery or procedure costs $______ /12 = $ ________
TRANSPORTATION TO MEDICAL CARE
Appointments per month: ______
Round-trip miles each: ______ x ______ = ______ miles/month
at the applicable mileage rate $ ________
Bus, taxi, or rideshare fares $ ________
Parking and tolls $ ________
TOTAL MONTHLY MEDICAL EXPENSE $ ________
DOCUMENTATION ATTACHED
[ ] Pharmacy printout for the last 12 months — ASK FOR IT, IT IS FREE
[ ] Social Security award letter showing the Medicare premium deduction
[ ] Insurance premium statements
[ ] Receipts for equipment and supplies
[ ] Provider bills and payment records
[ ] Appointment log with dates and destinations for the mileage claim
[ ] Veterinary and food receipts for a service animal
[ ] Statement from the attendant or aide
NOTE: A household with an elderly or disabled member is generally EXEMPT
FROM THE GROSS INCOME TEST, and the EXCESS SHELTER DEDUCTION CAP DOES NOT
APPLY. Confirm both are being applied. See Worksheet 4.
4. Shelter cost worksheet
SHELTER COST WORKSHEET
Rent, OR mortgage principal and interest $ ________
Property taxes (annual $______ / 12) $ ________
Homeowner's or renter's insurance
(annual $______ / 12) $ ________
HOA or condo fees $ ________
Second mortgage / home equity payment $ ________
Lot rent (manufactured home) $ ________
Repairs to a home damaged by a disaster,
not reimbursed $ ________
SUBTOTAL — HOUSING $ ________
UTILITIES [Many states use a STANDARD UTILITY ALLOWANCE instead of
actual costs. Ask which applies and which is higher for you.]
Electricity $ ________
Heating fuel (gas, oil, propane, wood, kerosene) $ ________
Water $ ________
Sewer $ ________
Trash collection $ ________
Telephone (basic service) $ ________
Air conditioning cost or fee $ ________
Installation or initial connection fees $ ________
SUBTOTAL — UTILITIES $ ________
TOTAL SHELTER COST $ ________
QUESTIONS TO ASK THE AGENCY IN WRITING
[ ] Which standard utility allowance am I receiving, and is there a
higher one I qualify for?
[ ] I receive home energy assistance — does that qualify me for the
higher allowance?
[ ] My household includes a member who is [60 or older / disabled].
Confirm that the excess shelter deduction CAP is not being applied.
[ ] Confirm the gross income test is not being applied to my household.
DOCUMENTATION ATTACHED
[ ] Lease or mortgage statement
[ ] Property tax bill
[ ] Insurance declarations page
[ ] 12 months of utility bills for each utility
[ ] Energy assistance award letter
5. Dependent care statement
STATEMENT OF DEPENDENT CARE COSTS
I pay for care of a dependent so that I can [work / look for work /
attend training / attend school].
Dependent cared for: ______________ Age: ______
Care provider: ______________________
Provider address: ______________________
Relationship (if any): ______________________
Days and hours of care: ______________________
Amount paid: $ ______ per [week / month]
Method of payment: [cash / check / transfer / app]
Care began: ____/____/______
This care is necessary because my [work / school] schedule is
______________________ and no one else in the household is available to
provide it.
______________________ Date: ________
---
PROVIDER STATEMENT
I, ______________, provide care for ______________ at [address] on the
following schedule: ______________________.
[Applicant] pays me $ ______ per [week / month] for this care. I have
provided this care since ____/____/______.
I understand this statement is being provided to a public benefits
agency.
______________________ · [Phone] · [Address] Date: ________
NOTE: Informal arrangements COUNT. A neighbor, a relative outside the
household, or a family friend who is paid for care qualifies. A signed
statement plus a record of payments is generally sufficient — do not
skip this deduction because there is no formal daycare invoice.
6. Verification cover sheet
Use this every single time you hand the agency anything.
VERIFICATION SUBMISSION
Name: ______________ Case/application number: ______________
Date submitted: ____/____/______
Submitted by: [ ] in person [ ] fax [ ] mail [ ] portal [ ] email
Submitted to: ______________________
ENCLOSED — [__] pages total, numbered 1 through ____
1. ______________________________________ (pages ____ to ____)
2. ______________________________________ (pages ____ to ____)
3. ______________________________________ (pages ____ to ____)
4. ______________________________________ (pages ____ to ____)
5. ______________________________________ (pages ____ to ____)
REQUESTED BUT NOT ENCLOSED
Item: ______________________
Reason: [ ] does not exist [ ] cannot be obtained [ ] requested from
______________ on ________, awaiting response
What I am providing instead: ______________________
I request the agency's assistance in obtaining this verification.
All documents submitted are COPIES. I retain the originals and can
produce them on request.
Please date-stamp the enclosed copy of this cover sheet and return it to
me.
______________________ · [Phone] · [Address]
AGENCY USE — RECEIVED BY: ______________ DATE: ________
7. Change report letter
[Date]
[Agency name and address]
RE: Reported change — case number ______________
Name: ______________
I am reporting the following change:
[ ] Income change
Employer: ______________________
Started / ended / changed on: ____/____/______
New gross amount: $ ______ per [hour/week/month]
Hours: ______ per week
First paycheck date: ____/____/______
[ ] Household member moved IN / OUT
Name: ______________ Relationship: ______________
Date: ____/____/______
[ ] Address change
New address: ______________________________
Effective: ____/____/______
[ ] Shelter cost change
Rent changed from $______ to $______ on ____/____/______
Utility change: ______________________
[ ] NEW OR INCREASED MEDICAL EXPENSE (this may INCREASE my benefit)
Description: ______________________
Monthly amount: $ ______
[ ] NEW DEPENDENT CARE COST (this may INCREASE my benefit)
Amount: $ ______ per ______
[ ] Other: ______________________________
ENCLOSED: ______________________________
I am reporting this in writing to create a record. I previously reported
this by telephone on ____/____/______ to ______________ [if applicable].
Please confirm receipt and advise if any additional verification is
needed.
______________________ · [Phone] · [Address]
RETAIN: a copy of this letter, the date stamp or fax confirmation, and
the postal or portal receipt. "You failed to report" is the most common
basis for an overpayment claim, and this page is the answer to it.
8. Fair hearing request
File within the SHORT deadline. This is the most important template here.
[Date — FILE WITHIN THE DEADLINE ON THE NOTICE, OFTEN 10 DAYS]
[Agency name — hearings unit]
[Address / fax]
RE: REQUEST FOR FAIR HEARING
Name: ______________
Case number: ______________
Notice dated: ____/____/______, received ____/____/______
Action: [reduction / termination / denial / overpayment claim /
sanction / failure to act]
I request a fair hearing on the action described in the notice above.
I DISAGREE WITH THE DECISION BECAUSE:
[One or two plain sentences. Examples:
"The notice counts my roommate's income. She buys and prepares her
food separately from my household."
"The notice uses a month in which I received three paychecks as my
ordinary monthly income. I am paid biweekly."
"The agency did not apply the medical expense deduction for my
mother, who is 72 and disabled."
"I reported this change on [date] and have the receipt."]
I REQUEST THAT MY BENEFITS CONTINUE AT THE CURRENT LEVEL WHILE THIS
APPEAL IS PENDING. I am making this request within the time period
required for continued benefits.
I ALSO REQUEST:
[ ] A complete copy of my case file, including all budget worksheets
showing the agency's calculations, all notices sent to me, all
verification I submitted, all change reports, and all case notes.
I request this at no cost and in advance of the hearing.
[ ] An interpreter in ______________.
[ ] The following accommodation for a disability: ________________.
[ ] A telephone hearing.
[ ] The name and contact information for free legal services in my
area.
I understand that if I do not prevail, continued benefits may be subject
to recovery.
______________________ · [Phone] · [Address] · [Email]
DELIVERY — keep proof:
[ ] Hand-delivered; date-stamped copy received
[ ] Faxed to ____________ on ________; confirmation retained
[ ] Certified mail, tracking ____________
[ ] Portal submission, confirmation number ____________
9. Case file request
[Date]
RE: Request for complete case file
Name: ______________ Case number: ______________
Fair hearing requested on ____/____/______
In connection with my pending fair hearing, I request a complete copy of
my case record, including:
1. My application(s) and recertification packet(s) as submitted
2. ALL BUDGET WORKSHEETS AND CALCULATION SHEETS for every month at
issue, showing income used, household members counted, each
deduction applied, and the resulting benefit
3. Every notice sent to me, with the date sent and the address used
4. Every change report I submitted, with date-received stamps
5. All verification I submitted
6. All verification requests sent to me, with dates
7. All case notes and narrative entries
8. Any interview records
9. Any third-party information relied on, including data matches
10. Any overpayment calculation, month by month
11. The specific regulation or policy provision relied on for the action
I request these documents at no cost and sufficiently in advance of the
hearing to review them. If any document is withheld, please identify it
and state the basis.
______________________ · [Phone] · [Address]
10. Budget worksheet audit
Do this the day the file arrives. The error is usually on one page.
BUDGET WORKSHEET AUDIT — month of ____________
WHAT THE AGENCY USED WHAT IS ACTUALLY TRUE
Household members counted: Should be:
____________________ ____________________
____________________ ____________________
____________________ ____________________
[ ] Someone counted who is NOT in my household — see Template 2
Earned income: $ ________ $ ________
Source of the agency's figure: ____________________
[ ] Wrong pay period used
[ ] THREE-PAYCHECK MONTH treated as ordinary monthly income
[ ] Gross used where net was appropriate, or vice versa
[ ] Income of a non-household member included
[ ] Overtime or a one-time bonus treated as ongoing
[ ] Seasonal income not averaged; averaged over best months only
Unearned income: $ ________ $ ________
[ ] Income that is excluded was counted
[ ] Amount is wrong
DEDUCTIONS APPLIED SHOULD BE
Standard: $ ________ $ ________
Earned income: $ ________ $ ________
Dependent care: $ ________ $ ________ [ ] NOT APPLIED
Child support: $ ________ $ ________ [ ] NOT APPLIED
Medical: $ ________ $ ________ [ ] NOT APPLIED
Excess shelter: $ ________ $ ________ [ ] CAP WRONGLY APPLIED
Utility allowance:$ ________ $ ________ [ ] LOWER ONE USED
Gross income test applied? Yes / No
[ ] Should NOT have been — household includes an elderly or disabled
member
RESULTING BENEFIT: $ ________ Should be: $ ________
THE ERROR, IN ONE SENTENCE:
______________________________________________________________
______________________________________________________________
EXHIBITS THAT PROVE IT:
____ ______________________________
____ ______________________________
____ ______________________________
11. Hearing summary sheet
Hand this up at the start. One page. It changes how the hearing goes.
SUMMARY FOR THE HEARING OFFICER
Appellant: ______________ Case number: ______________
Hearing date: ____/____/______
Notice appealed: dated ____/____/______
THE ACTION
The agency [reduced / terminated / denied] benefits effective
____/____/______.
THE AGENCY'S STATED REASON
"[Quote the notice exactly.]"
THE ISSUE
[One sentence. "Whether [Name], who lives at the same address, is part
of the appellant's household."]
THE ERROR
[Two or three sentences, factual.]
THE CORRECT FIGURES
Agency's figure Correct figure Exhibit
____________________ ________________ ____
____________________ ________________ ____
____________________ ________________ ____
Correct benefit amount: $ ________
RELIEF REQUESTED
1. Reversal of the [reduction / termination / denial].
2. Correction of the benefit to $ ______ per month.
3. RESTORATION OF BENEFITS for the months of ____________ through
____________, in the amount of $ ______.
4. [Correction of the household composition in the agency's records.]
AUTHORITY
[Cite what you can: the regulation on household composition, the
deduction provision, the notice requirements. Even a plain reference
helps: "7 C.F.R. Part 273 governs certification of eligible
households."]
EXHIBITS: see attached index.
12. Exhibit index
EXHIBIT INDEX
Appellant: ______________ Case number: ______________
Hearing date: ____/____/______
EX. DESCRIPTION DATE PAGES
1 Notice of adverse action appealed ________ ____
2 Fair hearing request with proof of
delivery ________ ____
3 Agency budget worksheet from case file ________ ____
4 Pay statements, 12 months ________ ____
5 Employer letter confirming hours and pay ________ ____
6 Lease / mortgage statement ________ ____
7 Utility bills, 12 months ________ ____
8 Pharmacy printout, 12 months ________ ____
9 Social Security award letter (Medicare
premium) ________ ____
10 Insurance premium statements ________ ____
11 Medical appointment log with mileage ________ ____
12 Dependent care provider statement and
payment records ________ ____
13 Child support order and payment history ________ ____
14 Separate household statement + companion
statement + proof ________ ____
15 Change report with date stamp ________ ____
16 Verification cover sheet with date stamp ________ ____
17 Call log ________ ____
18 ______________________________ ________ ____
THREE COPIES PREPARED:
[ ] Hearing officer [ ] Agency representative [ ] Mine
ALL PAGES NUMBERED: [ ] yes
13. Overpayment calculation challenge
[Date]
RE: Challenge to overpayment claim
Name: ______________ Case number: ______________
Claim number: ______________ Amount claimed: $ ____________
Notice dated: ____/____/______
I dispute this overpayment claim and request a fair hearing. I also
request the complete month-by-month calculation supporting it, including
for each month: the income used and its source, the household members
counted, each deduction applied, the benefit issued, and the benefit the
agency now says was correct.
ERRORS IDENTIFIED SO FAR
MONTH AGENCY SAYS ACTUALLY WAS PROBLEM
________ $ ________ $ ________ [ ] I received no benefits
this month
________ $ ________ $ ________ [ ] Income figure is wrong
________ $ ________ $ ________ [ ] Deduction omitted from the
recalculation
________ $ ________ $ ________ [ ] Household composition wrong
________ $ ________ $ ________ [ ] Duplicates claim number
____________
CATEGORY OF THE CLAIM
The notice classifies this as [agency error / inadvertent household
error / intentional program violation].
[ ] I dispute the classification. This is AGENCY ERROR because I
reported [the change] on [date]. My change report, with the
agency's date stamp, is enclosed. The agency received the
information and did not act on it.
[ ] The recovery rate should reflect the agency error classification.
DEFENSES RAISED
[ ] The underlying eligibility determination is incorrect (see the
accompanying hearing request).
[ ] The calculation is incorrect as set out above.
[ ] I request a COMPROMISE or WAIVER of the claim.
[ ] I request a REDUCED RECOUPMENT RATE based on financial hardship.
My monthly income is $______ and my necessary expenses are $______.
[ ] This claim covers months more than [__] years old and may not be
collectible.
I request that recoupment be suspended while this appeal is pending.
______________________ · [Phone] · [Address]
14. Response to a disqualification hearing notice
Read this before signing anything the agency sends about a "violation."
IF YOU RECEIVE A NOTICE ABOUT AN INTENTIONAL PROGRAM VIOLATION OR AN
ADMINISTRATIVE DISQUALIFICATION HEARING:
STOP. DO NOT SIGN THE WAIVER.
The form asking you to "waive your right to a hearing" is not routine
paperwork. Signing it means:
- accepting a finding that you INTENTIONALLY violated program rules,
- accepting a DISQUALIFICATION PERIOD (which escalates for repeat
findings, and can be permanent),
- giving up the hearing at which the agency would have to PROVE the
intent by a higher standard than an ordinary overpayment requires.
An honest mistake, a misunderstood reporting rule, or an agency's failure
to process what you reported is NOT an intentional program violation.
---
RESPONSE TEMPLATE
[Date]
RE: Notice of Administrative Disqualification Hearing
Name: ______________ Case number: ______________
Hearing scheduled: ____/____/______
I do NOT waive my right to a hearing. I will appear and contest the
allegation.
I deny that I intentionally made a false statement, concealed
information, or misrepresented facts. Specifically:
[ ] I reported the information in question on ____/____/______.
Proof enclosed: [change report with date stamp / call log /
verification cover sheet].
[ ] I was not required to report this under the reporting rules that
applied to my case. My approval notice states that I am subject to
[simplified / change] reporting with a threshold of $______.
[ ] I misunderstood the requirement. [Explain honestly what you
believed and why.]
[ ] The information was on my application and the agency had it.
[ ] Other: ______________________________
I REQUEST:
[ ] A complete copy of my case file and all evidence the agency intends
to present at the hearing, in advance
[ ] The name and contact information for free legal services
[ ] An interpreter in ______________
[ ] [Accommodation]: ______________________
I intend to be represented. Please direct further correspondence to me
and to my representative once designated.
______________________ · [Phone] · [Address]
CALL LEGAL AID TODAY. These proceedings carry consequences well beyond
repayment, and legal aid handles them for free.
15. Work requirement exemption letter
[Date]
RE: Exemption from work requirements / time limit
Name: ______________ Case number: ______________
I am exempt from the [general work requirement / ABAWD time limit] for
the following reason(s):
[ ] I am physically or mentally unfit for employment.
Documentation: enclosed provider statement.
NOTE: this does NOT require a formal disability determination.
[ ] I am pregnant. Due date: ____/____/______
[ ] I live in a household with a child under 18: [name, age].
THE CHILD DOES NOT HAVE TO BE MINE.
[ ] I am already meeting the work requirement. I work ______ hours per
week at ______________ [including irregular, seasonal, or
self-employment work]. Documentation enclosed.
[ ] I receive unemployment compensation.
[ ] I am participating in a substance use treatment program at
______________.
[ ] I am enrolled at least half time at ______________.
[ ] I am a veteran. [ ] I am experiencing homelessness.
[ ] I aged out of foster care.
[ ] I am caring for an incapacitated person: [name, relationship].
[ ] I live in [county], which I believe is subject to a waiver based on
unemployment or insufficient jobs. PLEASE CONFIRM WHETHER MY COUNTY
IS WAIVED.
Please confirm in writing that the exemption has been applied to my case,
effective ____/____/______.
______________________ · [Phone] · [Address]
---
PROVIDER STATEMENT — give this structure to the medical professional
[Provider letterhead] [Date]
To Whom It May Concern:
[Name], date of birth ________, has been my patient since ________.
[He/She/They] has [diagnosis/condition], which results in [specific
functional limitations: inability to stand or walk for more than __
minutes; inability to lift more than __ pounds; inability to maintain a
regular schedule; inability to sustain concentration; frequent
hospitalizations].
In my professional opinion, [Name] is not currently able to work or to
participate in work training or employment activities.
This condition [is permanent / is expected to persist for at least
______ months / will be reassessed on ________].
______________________
[Signature, printed name, credentials, license number, practice address,
phone]
16. Good cause statement
STATEMENT OF GOOD CAUSE
Name: ______________ Case number: ______________
Requirement missed: ______________________
Date missed: ____/____/______
I had good cause for not [attending the appointment / participating in
the assigned activity / accepting the employment / providing the
verification] because:
[ ] ILLNESS — mine or a household member's.
What happened: ______________________________
Documentation: ______________________________
[ ] HOUSEHOLD EMERGENCY
What happened: ______________________________
[ ] NO CHILD CARE was available.
I contacted: ______________ on ________, result: ____________
I contacted: ______________ on ________, result: ____________
[ ] NO TRANSPORTATION was available.
The location was ______ miles away. Public transit [does not serve
it / would have required ______ hours]. My vehicle [was inoperable
from ________ to ________ / I do not have one].
[ ] THE JOB paid below minimum wage, or required hours or conditions
not previously agreed to: ______________________
[ ] DISCRIMINATION: ______________________________
[ ] DOMESTIC VIOLENCE. [See the note below — ask about a waiver.]
[ ] I NEVER RECEIVED THE NOTICE. It was sent to [address], which has
not been my address since ________. I reported my address change
on ________ [proof enclosed].
[ ] OTHER CIRCUMSTANCE BEYOND MY CONTROL: ______________
I request that no sanction be imposed, or that any sanction already
imposed be rescinded, and that any benefits lost be restored.
______________________ · [Phone] Date: ________
TANF NOTE — TWO PROVISIONS TO REQUEST BY NAME:
1. DOMESTIC VIOLENCE WAIVER. In many states this excuses work
requirements, extends time limits, and waives child support
cooperation. Ask for it explicitly.
2. GOOD CAUSE EXCEPTION TO CHILD SUPPORT COOPERATION, where
cooperation would risk harm to you or a child. This exists
everywhere and is one of the least-used protections in the system.
3. If approaching a lifetime limit, ask about the HARDSHIP EXCEPTION
BEFORE you reach it.
17. Appeal for failure to act
[Date]
RE: REQUEST FOR FAIR HEARING — FAILURE TO ACT
Name: ______________
Application filed: ____/____/______
Application/case number: ______________
I applied for [SNAP / TANF / other] on ____/____/______. As of today,
______ days have elapsed and I have received no decision.
[ ] I requested EXPEDITED SERVICE on ________. The expedited processing
period has passed.
[ ] The standard processing period has passed.
[ ] I submitted all requested verification on ________ [proof enclosed]
and have received no decision.
I am requesting a fair hearing on the agency's failure to act on my
application with reasonable promptness.
CONTACTS I HAVE MADE
Date ________ Spoke to ______________ Told: ______________
Date ________ Spoke to ______________ Told: ______________
Date ________ Spoke to ______________ Told: ______________
CONSEQUENCES OF THE DELAY
[State them concretely: no food in the home; a utility shutoff on
[date]; an eviction filing; a medical need.]
I request an immediate decision on my application, and a hearing if one
is not issued.
______________________ · [Phone] · [Address]
cc: [Supervisor name] · [Agency ombudsman] · [State legislator's
constituent services office]
ESCALATION LADDER
1. Assigned worker — get a name and a date
2. Supervisor, by name, in writing
3. Agency ombudsman or constituent services
4. This fair hearing request on failure to act
5. LEGAL AID — an advocate's call often resolves in a day
6. State legislator's constituent services office — free and underused
18. Call log
Keep this in the front of the folder. It is evidence; memory is not.
CONTACT LOG — [Name], case number ______________
DATE TIME SPOKE TO / OFFICE SUBJECT RESULT / WHAT
I WAS TOLD
______ ______ ____________________ __________________ ______________
______ ______ ____________________ __________________ ______________
______ ______ ____________________ __________________ ______________
______ ______ ____________________ __________________ ______________
______ ______ ____________________ __________________ ______________
DOCUMENTS SUBMITTED
DATE WHAT HOW PROOF HELD
______ __________________________ ____________ __________________
______ __________________________ ____________ __________________
______ __________________________ ____________ __________________
NOTICES RECEIVED
DATE ON DATE WHAT IT SAID DEADLINE ACTION TAKEN
NOTICE RECEIVED (WRITE IT!)
________ ________ ______________________ ________ ______________
________ ________ ______________________ ________ ______________
CASE SUMMARY — keep this current at the front of the folder
Case number: ______________
Worker name and number: ______________________
Office address: ______________________
My reporting system: [ ] simplified, threshold $______
[ ] change reporting
Recertification date: ____/____/______
Household as the agency has it: ______________________
My household as it actually is: ______________________
Legal aid contact: ______________________
Related documents
- SNAP, TANF, and Public Assistance: Eligibility, Fair Hearings, and Overpayments
- Applying for and Keeping Public Benefits
- Public Benefits Checklist
- Public and Subsidized Housing
- Utility Service: Shutoffs, Billing Disputes, and Assistance Programs
Templates only, not legal advice. Adapt to your facts and your state's rules. Framework: 7 U.S.C. § 2011 · § 2014 · § 2020 · 7 C.F.R. Part 273 · 42 U.S.C. § 601 · § 608 · Goldberg v. Kelly.
