Form HRP-1035A FORPDF "Commodity Senior Food Program (Csfp) Notification of Discontinuance" - Arizona

What Is Form HRP-1035A FORPDF?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form HRP-1035A FORPDF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form HRP-1035A FORPDF "Commodity Senior Food Program (Csfp) Notification of Discontinuance" - Arizona

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CSFP
Commodity
Senior Food
Program
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1035A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
NOTIFICATION OF DISCONTINUANCE
APPLICANT NAME
NOTICE DATE
Your participation in the Commodity Senior Food Program is being DISCONTINUED for the following reason:
Program benefits will end on:
If any of the above changes, you may reapply for services.
Health and/or public assistance referral made?
Yes
No
If you do not agree with this decision and wish to appeal, your appeal request may be submitted verbally or in writing.
Requests for an informal dispute resolution meeting must be submitted within twenty (20) calendar days from the Notice
Date at the top of this form. Requests for a fair hearing must be submitted within sixty (60) calendar days from the Notice
Date at the top of this form.
An informal dispute resolution meeting is an informal meeting between you, the distribution site director, involved
distribution site staff and a representative from the Department of Economic Security (DES), who will preside over the
meeting. If you request an informal dispute resolution meeting, DES will notify you of the time, date and meeting procedure
at least fifteen (15) calendar days before the meeting.
If you do not wish to request an informal dispute resolution meeting, you may request a fair hearing. You may also request
a fair hearing to appeal the decision made in an informal dispute resolution meeting. A fair hearing is an administrative
hearing before an impartial DES official. A decision is made within forty-five (45) days from the date the fair hearing request
was received. The fair hearing request must contain a statement of facts, the reasons you believe you are entitled to a fair
hearing and the relief sought. At a fair hearing, you have the right to self-representation or to be represented by a relative,
friend, legal counsel or other spokesperson. You also have the right to bring witnesses, introduce arguments, question or
refute testimony or evidence, confront and cross-examine adverse witnesses and submit evidence to support your case.
To request an informal dispute resolution meeting or fair hearing, contact your Distribution Site to get an Informal Dispute
Resolution Meeting/Fair Hearing Request form, complete the form and mail or fax it to:
Division of Aging and Adult Services, Office of the Assistant Director
1789 W. Jefferson St., Mail Drop 6271, Phoenix, AZ 85007
Phone: (602) 542-4446 | Fax: (602) 542-6575
You may also request an informal dispute resolution or fair hearing by contacting your Distribution Site or calling the DES
Coordinated Hunger Relief Program at: (602) 771-2788.
If you choose to appeal and file your request within fifteen (15) calendar days from the Notice Date at the top of this form,
you may continue to receive program benefits during the appeal process until the hearing officer reaches a decision or your
certification period ends, whichever comes first. You cannot continue to receive benefits when benefits were denied at the
initial certification or your certification period has expired.
Program standards are applied without discrimination based on based on race, color, national origin, sex, disability, age or
reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
CLIENT/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
DISTRIBUTION SITE STAFF SIGNATURE
DATE
See reverse for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
CSFP
Commodity
Senior Food
Program
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1035A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
NOTIFICATION OF DISCONTINUANCE
APPLICANT NAME
NOTICE DATE
Your participation in the Commodity Senior Food Program is being DISCONTINUED for the following reason:
Program benefits will end on:
If any of the above changes, you may reapply for services.
Health and/or public assistance referral made?
Yes
No
If you do not agree with this decision and wish to appeal, your appeal request may be submitted verbally or in writing.
Requests for an informal dispute resolution meeting must be submitted within twenty (20) calendar days from the Notice
Date at the top of this form. Requests for a fair hearing must be submitted within sixty (60) calendar days from the Notice
Date at the top of this form.
An informal dispute resolution meeting is an informal meeting between you, the distribution site director, involved
distribution site staff and a representative from the Department of Economic Security (DES), who will preside over the
meeting. If you request an informal dispute resolution meeting, DES will notify you of the time, date and meeting procedure
at least fifteen (15) calendar days before the meeting.
If you do not wish to request an informal dispute resolution meeting, you may request a fair hearing. You may also request
a fair hearing to appeal the decision made in an informal dispute resolution meeting. A fair hearing is an administrative
hearing before an impartial DES official. A decision is made within forty-five (45) days from the date the fair hearing request
was received. The fair hearing request must contain a statement of facts, the reasons you believe you are entitled to a fair
hearing and the relief sought. At a fair hearing, you have the right to self-representation or to be represented by a relative,
friend, legal counsel or other spokesperson. You also have the right to bring witnesses, introduce arguments, question or
refute testimony or evidence, confront and cross-examine adverse witnesses and submit evidence to support your case.
To request an informal dispute resolution meeting or fair hearing, contact your Distribution Site to get an Informal Dispute
Resolution Meeting/Fair Hearing Request form, complete the form and mail or fax it to:
Division of Aging and Adult Services, Office of the Assistant Director
1789 W. Jefferson St., Mail Drop 6271, Phoenix, AZ 85007
Phone: (602) 542-4446 | Fax: (602) 542-6575
You may also request an informal dispute resolution or fair hearing by contacting your Distribution Site or calling the DES
Coordinated Hunger Relief Program at: (602) 771-2788.
If you choose to appeal and file your request within fifteen (15) calendar days from the Notice Date at the top of this form,
you may continue to receive program benefits during the appeal process until the hearing officer reaches a decision or your
certification period ends, whichever comes first. You cannot continue to receive benefits when benefits were denied at the
initial certification or your certification period has expired.
Program standards are applied without discrimination based on based on race, color, national origin, sex, disability, age or
reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
CLIENT/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
DISTRIBUTION SITE STAFF SIGNATURE
DATE
See reverse for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
HRP-1035A FORPDF (8-17) – Reverse
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies,
the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are
prohibited from discriminating based on race, color, national origin, sex, disability, age or reprisal or retaliation for prior civil
rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print,
audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service
at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027)
found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed
to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call
(866) 632-9992. Submit your completed form or letter to USDA by:
(1)
mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)
fax:
(202) 690-7442; or
(3)
email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
• Disponible en español en línea o en la oficina local.
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