Form HRP-1032A FORPDF "Commodity Senior Food Program (Csfp) Informal Dispute Resolution Meeting / Fair Hearing Request" - Arizona

What Is Form HRP-1032A 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form HRP-1032A 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-1032A FORPDF "Commodity Senior Food Program (Csfp) Informal Dispute Resolution Meeting / Fair Hearing Request" - Arizona

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CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1032A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
INFORMAL DISPUTE RESOLUTION MEETING / FAIR HEARING REQUEST
CLIENT INFORMATION
CLIENT NAME
DATE OF BIRTH
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NUMBER
DISTRIBUTION SITE NAME
DISTRIBUTION SITE ADDRESS
CITY
STATE
ZIP CODE
Check the appropriate box to request a fair hearing or informal dispute resolution meeting, then complete the remainder
of the form.
I want a FAIR HEARING for CSFP
I want an INFORMAL DISPUTE RESOLUTION MEETING for CSFP
I am making this request because I do not agree with:
Discontinuance of Benefits  
Denial of Application
Overpayment or Disqualification
Other (explain):
I disagree with the decision for the following reason(s):
Date of the notice I do not agree with:
I need an interpreter:
Yes
No
If yes, what language?
IMPORTANT: Read your fair hearing rights on the back of this form before filling out this section.
I DO want to keep getting benefits during my fair hearing (fair hearing requests only).
I DO NOT want to keep getting benefits during my fair hearing (fair hearing requests only).
CLIENT/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
See reverse for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1032A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
INFORMAL DISPUTE RESOLUTION MEETING / FAIR HEARING REQUEST
CLIENT INFORMATION
CLIENT NAME
DATE OF BIRTH
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NUMBER
DISTRIBUTION SITE NAME
DISTRIBUTION SITE ADDRESS
CITY
STATE
ZIP CODE
Check the appropriate box to request a fair hearing or informal dispute resolution meeting, then complete the remainder
of the form.
I want a FAIR HEARING for CSFP
I want an INFORMAL DISPUTE RESOLUTION MEETING for CSFP
I am making this request because I do not agree with:
Discontinuance of Benefits  
Denial of Application
Overpayment or Disqualification
Other (explain):
I disagree with the decision for the following reason(s):
Date of the notice I do not agree with:
I need an interpreter:
Yes
No
If yes, what language?
IMPORTANT: Read your fair hearing rights on the back of this form before filling out this section.
I DO want to keep getting benefits during my fair hearing (fair hearing requests only).
I DO NOT want to keep getting benefits during my fair hearing (fair hearing requests only).
CLIENT/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
See reverse for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
   
   
     
   
   
   
   
   
   
   
   
   
     
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
     
   
  
   
   
   
   
   
    
   
   
   
   
   
   
   
   
   
    
   
   
  
   
   
   
   
   
  
   
   
   
   
   
   
   
   
   
     
   
   
   
   
   
YOUR FAIR HEARING RIGHTS
HRP-1032A FORPDF (8-17) – Reverse
You must be provided with a written explanation when a decision is made on your case. A fair hearing is a process that
allows a Commodity Senior Food Program applicant or participant to appeal an adverse action, which may include the
denial or discontinuance of program benefits, disqualification from the program or a claim to repay the value of commodities
received as a result of fraud.
You have the right to:
• Examine documents supporting the State or local agency’s decision before and during the hearing;
• Be assisted or represented by an attorney or other persons;
• Bring witnesses;
• Present arguments;
• Question or refute testimony or evidence, including an opportunity to confront and cross-examine others at the hearing;
and
• Submit evidence to help establish facts and circumstances.
What happens after you ask for a fair hearing?
• The Department of Economic Security (DES) will send you a notice, at least fifteen (15) days in advance, with the time,
date and location of the meeting along with the name of the hearing official.
• You may withdraw your fair hearing request or convert it to an informal dispute resolution meeting request at any time by
contacting your Distribution Site or the DES Coordinated Hunger Relief Program at: (602) 771-2788.
How do you ask for a fair hearing?
• You can get an Informal Dispute Resolution Meeting/Fair Hearing Request form from your Distribution Site or by calling
the DES Coordinated Hunger Relief Program at: (602) 771-2788.
• Drop off your completed form at your Distribution Site, fax it to DES at (602) 542-6575 or mail it to: Division of Aging and
Adult Services, Office of the Assistant Director, 1789 W. Jefferson St., 2nd Floor, Mail Drop 6271, Phoenix, AZ 85007.
How can you keep getting benefits while you wait for a fair hearing?
• You may continue to receive benefits if you ask for a fair hearing within fifteen (15) days of the date on the decision notice.
• You may not continue to receive benefits while waiting for a fair hearing if your application was denied, a change in the
law caused the decision to be made or your benefits were stopped because your certification period expired.
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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