Status message

The form below must be entirely filled out and should include any details you believe would be helpful to the hearing officer. Once your hearing request is received with all the necessary information, an appeal will be set up, assigned to a hearing officer, and you will receive an acknowledgement letter in the mail.

I Am

The applicant and/or recipient Representing the applicant or recipient

Applicant/Recipient Information

First Name

Last Name

Address Line 1

Address Line 2

City/Town

State

ZIP/Postal Code

County of Residence

Email Address

Phone

Which identifying information will you enter?

Appeal Information

What programs are you appealing? For any other program not listed please call our office.

Food Assistance Medicaid Cash Assistance SSI Direct Assistance Medicaid Termination

What is the date on the Notice of Agency Action?

What action are you appealing? Select all the actions that apply.

Application denial Benefit amount Reduction in benefits Termination of ongoing benefits Delay in receiving benefits

If you ask for a hearing by the end of the last day of the month prior to the effective date of the adverse action, your benefits may continue at the prior level until the hearing decision. You will be responsible to repay any benefits continued if the hearing decision is not in your favor.

If the Department's action is a reduction or termination of benefits, are you seeking continued benefits while the hearing is pending?

Yes No

Describe the action the Department took and why you disagree with the action

Will you need a special accommodation or professional language interpreter at the hearing?

Yes No

An unhandled error has occurred. Reload 🗙

Connection Lost

We lost connection to the server. Attempting to reconnect…

Reconnecting automatically…

Your form data may still be available after reloading.
If the problem persists, please try again later.