Form NA Back 9 "Your Hearing Rights (Full Rights Are Listed in Cdss Pub 412)" - California

What Is Form NA Back 9?

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

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the California Department of Social 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 NA Back 9 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form NA Back 9 "Your Hearing Rights (Full Rights Are Listed in Cdss Pub 412)" - California

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YOUR HEARING RIGHTS (Full Rights are Listed in CDSS PUB 412)
You can ask for a hearing if you disagree with an agency action, or its failure to act timely. You have 90 days to ask
for a hearing. That time starts the day after the date of mailing or hand-delivery of the notice to you. After 90 days,
you will have to prove that you have a good reason for asking for a hearing late.
HOW TO ASK FOR A HEARING
You can ask for a hearing by any of the following ways:
• Online at the
ACMS
website: Create an account
• In person: Take this page to the address listed on the
other side of this notice; OR
if you want your hearing information online or click
• Mail to: CDSS State Hearings Division, PO Box 94423,
“Submit Appeal without an Account”, OR
MS 21-37, Sacramento CA 94244-2430 OR
• Call toll free: (800) 743-8525 or for hearing or speech
• Fax to: (833) 281-0905 OR
impaired who use TDD (800) 952-8349 OR
• E-mail to:
SHDCSU@dss.ca.gov
• Fill out this page, make a copy for your records, then
deliver it to: (see next column)
HEARING REQUEST
1. I want a hearing about the action taken by __________________________ County/Agency about:  Cash Benefits
 Food Benefits  Foster Care  IHSS  Medi-Cal  Other (list): ________________________________
2. I want a hearing because: _____________________________________________________________________
___________________________________________________________________________________________
3. Print name of person asking for a hearing: ___________________________________Birthdate: ______________
4. Mailing Address: _____________________________________________________________________________
5. Phone No.: __________________________Email Address: ___________________________________________
 I want to get hearing notices from the State Hearings Division by email
6. Signature: __________________________________________ Date Signed: ______________________________
7. Interpreter Request (Friends/family are not permitted to interpret for you.)
 I would like a free interpreter. I need _____________________________ language or dialect.
8. Tell us how you want to attend your hearing:
 Telephone (parties speak with the judge over the phone)
 Video conference (you see and hear the judge on your phone, tablet, or computer)
 I do not have internet access and would like to go to a hearing site for a video hearing
 In-Person (you travel to a county hearing site; you and the judge are in a room)
 In-Person, but I have a disability/hardship and cannot go to the hearing site. Explain:
___________
____________________________________________________________________________________________________
9. Request for Faster Scheduled Hearing Because of an Urgent Situation:
I need a hearing faster because: _________________________________________________________________________
Denial of:
Expedited CalFresh Benefits  Immediate CalWORKs Benefits  Emergency Medi-Cal Services
 I am facing an eviction or homelessness  Other Emergency (Explain): _____________________________________
10. Keeping Aid While Waiting for a Decision: You must appeal before the action starts to keep the benefits the same.
 Check if you choose to lower or stop your benefits as listed in the agency notice. Note: If you do not win
your hearing issue, you have to pay back any extra Cash Aid, CalFresh, or Child Care benefits you were paid.
11. Request for Reasonable Accommodation for Disability
 I need reasonable accommodations for my disability:  Sign Language Interpreter  Large Print
 Other: __________________________________________________________________________________
12. Appointment of Representative For Hearing
 I give permission for this friend, relative, or organization to help me at my hearing, and/or see my agency records.
They have agreed to represent me. Name/Organization: _____________________________________________
Mailing Address: _____________________________________________________________________________
Phone No: _________________________ Email:____________________________________________________
13. To Get Help: These groups below may be able to give you legal advice or represent you at the hearing.
NA Back 9 (Revised 2/2021) - REQUIRED FORM - NO SUBSTITUTE PERMITTED
YOUR HEARING RIGHTS (Full Rights are Listed in CDSS PUB 412)
You can ask for a hearing if you disagree with an agency action, or its failure to act timely. You have 90 days to ask
for a hearing. That time starts the day after the date of mailing or hand-delivery of the notice to you. After 90 days,
you will have to prove that you have a good reason for asking for a hearing late.
HOW TO ASK FOR A HEARING
You can ask for a hearing by any of the following ways:
• Online at the
ACMS
website: Create an account
• In person: Take this page to the address listed on the
other side of this notice; OR
if you want your hearing information online or click
• Mail to: CDSS State Hearings Division, PO Box 94423,
“Submit Appeal without an Account”, OR
MS 21-37, Sacramento CA 94244-2430 OR
• Call toll free: (800) 743-8525 or for hearing or speech
• Fax to: (833) 281-0905 OR
impaired who use TDD (800) 952-8349 OR
• E-mail to:
SHDCSU@dss.ca.gov
• Fill out this page, make a copy for your records, then
deliver it to: (see next column)
HEARING REQUEST
1. I want a hearing about the action taken by __________________________ County/Agency about:  Cash Benefits
 Food Benefits  Foster Care  IHSS  Medi-Cal  Other (list): ________________________________
2. I want a hearing because: _____________________________________________________________________
___________________________________________________________________________________________
3. Print name of person asking for a hearing: ___________________________________Birthdate: ______________
4. Mailing Address: _____________________________________________________________________________
5. Phone No.: __________________________Email Address: ___________________________________________
 I want to get hearing notices from the State Hearings Division by email
6. Signature: __________________________________________ Date Signed: ______________________________
7. Interpreter Request (Friends/family are not permitted to interpret for you.)
 I would like a free interpreter. I need _____________________________ language or dialect.
8. Tell us how you want to attend your hearing:
 Telephone (parties speak with the judge over the phone)
 Video conference (you see and hear the judge on your phone, tablet, or computer)
 I do not have internet access and would like to go to a hearing site for a video hearing
 In-Person (you travel to a county hearing site; you and the judge are in a room)
 In-Person, but I have a disability/hardship and cannot go to the hearing site. Explain:
___________
____________________________________________________________________________________________________
9. Request for Faster Scheduled Hearing Because of an Urgent Situation:
I need a hearing faster because: _________________________________________________________________________
Denial of:
Expedited CalFresh Benefits  Immediate CalWORKs Benefits  Emergency Medi-Cal Services
 I am facing an eviction or homelessness  Other Emergency (Explain): _____________________________________
10. Keeping Aid While Waiting for a Decision: You must appeal before the action starts to keep the benefits the same.
 Check if you choose to lower or stop your benefits as listed in the agency notice. Note: If you do not win
your hearing issue, you have to pay back any extra Cash Aid, CalFresh, or Child Care benefits you were paid.
11. Request for Reasonable Accommodation for Disability
 I need reasonable accommodations for my disability:  Sign Language Interpreter  Large Print
 Other: __________________________________________________________________________________
12. Appointment of Representative For Hearing
 I give permission for this friend, relative, or organization to help me at my hearing, and/or see my agency records.
They have agreed to represent me. Name/Organization: _____________________________________________
Mailing Address: _____________________________________________________________________________
Phone No: _________________________ Email:____________________________________________________
13. To Get Help: These groups below may be able to give you legal advice or represent you at the hearing.
NA Back 9 (Revised 2/2021) - REQUIRED FORM - NO SUBSTITUTE PERMITTED