Form IL444-0103 "Appeal Request Form (Snap, Medical Assistance, Cash Assistance, Child Care)" - Illinois

What Is Form IL444-0103?

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

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Illinois Department of Human Services;
  • 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 IL444-0103 by clicking the link below or browse more documents and templates provided by the Illinois Department of Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form IL444-0103 "Appeal Request Form (Snap, Medical Assistance, Cash Assistance, Child Care)" - Illinois

Download PDF

Fill PDF online

Rate (4.7 / 5) 9 votes
State of Illinois
Department of Human Services
APPEAL REQUEST FORM (SNAP, MEDICAL
ASSISTANCE, CASH ASSISTANCE, CHILD CARE)
4cc3362d-9397-48aa-9f84-408acd0faede
Use this form only if you want to file an appeal (this is a request for a hearing). Your Family Community Resource Center (FCRC
or local office) may help you fill out this form. You may file this form with your FCRC or with the Bureau of Hearings at 69 W.
Washington, 4th Floor, Chicago, IL 60602; via email at DHS.BAH@Illinois.gov; Fax at (312) 793-3387; by Telephone at (800)
435-0774; or online at https://abe.illinois.gov/abe/access/appeals.
Appellant First Name:
Appellant Last Name:
Date of Birth:
Telephone Number:
Address: (No. & Street, Apt. No.)
City, County:
State, Zip Code:
Email Address:
Name Case is Under:
Case Number:
Social Security Number:
If Yes, what language?
Yes
No
Will you need an interpreter in the hearing?
I am appealing action taken on:
Long Term
Medical
AABD Cash
Child
SNAP
TANF
(check all that apply)
Care
Assistance
Assistance
Care
Application/Request Date:
Date of Department Notice you are appealing:
If you can, please provide your Notice of Decision with this Appeal Request Form.
I AM REQUESTING A FAIR HEARING BECAUSE:
My application/request was denied and I disagree with this
IDHS says I am not disabled and I disagree with this
I was enrolled in spenddown and I disagree with this
A penalty period was imposed and I disagree with this
I disagree with the benefit amount
I disagree with the beginning eligibility date
My benefits were stopped or reduced and I disagree with this
I was charged with an overpayment and I disagree with this
My SNAP benefits were recouped for a previous overpayment claim(s) and I disagree with this
Money was recovered on an overpayment claim(s) and I disagree with this
A sanction was imposed and I disagree with this
I asked to be exempt from the Department's work and training activities and I was denied
I requested Crisis Assistance and I was denied
IDHS has not taken action on my application or a request
Other Reason:
IL444-0103 (R-04-18) Appeal Request Form (SNAP, Medical Assistance, Cash Assistance, Child Care)
Page 1 of 2
Printed by Authority of the State of Illinois -0- Copies
State of Illinois
Department of Human Services
APPEAL REQUEST FORM (SNAP, MEDICAL
ASSISTANCE, CASH ASSISTANCE, CHILD CARE)
4cc3362d-9397-48aa-9f84-408acd0faede
Use this form only if you want to file an appeal (this is a request for a hearing). Your Family Community Resource Center (FCRC
or local office) may help you fill out this form. You may file this form with your FCRC or with the Bureau of Hearings at 69 W.
Washington, 4th Floor, Chicago, IL 60602; via email at DHS.BAH@Illinois.gov; Fax at (312) 793-3387; by Telephone at (800)
435-0774; or online at https://abe.illinois.gov/abe/access/appeals.
Appellant First Name:
Appellant Last Name:
Date of Birth:
Telephone Number:
Address: (No. & Street, Apt. No.)
City, County:
State, Zip Code:
Email Address:
Name Case is Under:
Case Number:
Social Security Number:
If Yes, what language?
Yes
No
Will you need an interpreter in the hearing?
I am appealing action taken on:
Long Term
Medical
AABD Cash
Child
SNAP
TANF
(check all that apply)
Care
Assistance
Assistance
Care
Application/Request Date:
Date of Department Notice you are appealing:
If you can, please provide your Notice of Decision with this Appeal Request Form.
I AM REQUESTING A FAIR HEARING BECAUSE:
My application/request was denied and I disagree with this
IDHS says I am not disabled and I disagree with this
I was enrolled in spenddown and I disagree with this
A penalty period was imposed and I disagree with this
I disagree with the benefit amount
I disagree with the beginning eligibility date
My benefits were stopped or reduced and I disagree with this
I was charged with an overpayment and I disagree with this
My SNAP benefits were recouped for a previous overpayment claim(s) and I disagree with this
Money was recovered on an overpayment claim(s) and I disagree with this
A sanction was imposed and I disagree with this
I asked to be exempt from the Department's work and training activities and I was denied
I requested Crisis Assistance and I was denied
IDHS has not taken action on my application or a request
Other Reason:
IL444-0103 (R-04-18) Appeal Request Form (SNAP, Medical Assistance, Cash Assistance, Child Care)
Page 1 of 2
Printed by Authority of the State of Illinois -0- Copies
State of Illinois
Department of Human Services
APPEAL REQUEST FORM (SNAP, MEDICAL
ASSISTANCE, CASH ASSISTANCE, CHILD CARE)
4cc3362d-9397-48aa-9f84-408acd0faede
Please Check One:
Under some programs, benefits may continue while the hearing decision is pending. If possible,
I WANT my benefits to continue until the hearing decision is made. I understand that if the decision is not in my favor,
I may have to pay back the benefits. I want the following benefits to continue:
Cash
SNAP
Cash and SNAP
Medical Assistance
I DO NOT WANT my benefits continued while the hearing decision is pending.
Do you want someone else to represent you at the hearing? If yes, provide their information in the space below.
Approved Representative
Telephone Number:
Email Address:
First Name, Last Name
Address (No. & Street, Apt. No.)
City, State, Zip Code
Representative's Firm (if applicable)
If signed by a person other than the appellant, you must attach written authorization to file an appeal on behalf of appellant.
Please note: You may submit your own written authorization or use Form IL444-0960 - Authorized Representative Form for
Appeals. Form IL444-2998 - Approved Representative Consent Form, will not be accepted for appeal representation.
Your Signature (or Signature of Approved Representative)
Date
Please Note: You are entitled by law to a final decision on your appeal and to full implementation of a decision favorable to
you within 90 days from the time you requested the appeal, unless you have requested a delay of your hearing. For SNAP
benefits only, you are entitled by law to a final decision on your appeal within 60 days and full implementation of a decision
favorable to you within 10 days of receipt of the hearing decision.
For IDHS Office Use Only: To be completed by the FCRC or Hearings
Date Notice of Appeal Received:
Date of Postmark, if mailed
Date of written request for
(attach envelope):
hearing, if preceding this form:
Date of Decision Being Appealed:
Case Name:
Case Number:
IL444-0103 (R-04-18) Appeal Request Form (SNAP, Medical Assistance, Cash Assistance, Child Care)
Page 2 of 2
Printed by Authority of the State of Illinois -0- Copies
Page of 2