SFN 162 - Request for Hearing 430-05-100-65

(Revised 01/01/04 ML2893)

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This form is completed by households that are requesting a hearing to dispute benefit reduction, suspension or termination.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (54 kb pdf)

 

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader.  If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.