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Get MI DHS-18 2005

Name of Authorized Hearing Representative DHS-18 Rev. 5-05 Previous edition obsolete. MS Word 21. Title. Telephone Number INSTRUCTIONS Complete items 12 through 18 below. Please type or print. DELIVER OR MAIL completed form to your local DHS office Attn Hearing Coordinator. If DHS proposed action is upheld I will be required to repay any additional benefits that I received because the proposed action was postponed. If I withdraw this hearing request or if I do not go to the hearing when it is scheduled I will be required to repay any additional benefits that I received because the proposed action was postponed I DO DO NOT want to continue receiving the amount of food assistance I now receive until after my hearing. 13. Signature of Person Requesting Hearing AH must receive an original signature. If this form is signed by an authorized hearing representative documentation of authorization must be attached. 16. Street Address or Route Number 17. City State and Zip Code 18. Are special arrangements required for you to participate in a hearing Yes 15. REQUEST FOR HEARING 1. Case Name Last State of Michigan Department of Human Services First 2. Address 3. A date-stamped copy will be returned to you by the local office. 5. County 6. District 4. Case Number 7. Section 8. Unit 9. Specialist 10. Date Received in DHS 11. Program s in Dispute ning n individuo o grupo a causa de su raza sexo religi n edad origen nacional color de piel estatura peso estado matrimonial creencias pol ticas o incapacidad* Si Ud. necesita ayuda para leer escribir o r etc* bajo la Acta de Americanos con Incapacidades usted esta invitado a hacer saber sus necesidades conocidas a una oficina de DHS en su condado. The Department of Human Services DHS will not discriminate against any individual or group because of race sex religion age national origin color height weight marital status political beliefs or disability. If you need help with reading writing hearing etc* under the Americans with Disabilities Act you are invited to make your needs known to a DHS office in your county. AUTHORITY MCL 400. 9 MSA 16 409 RESPONSE Voluntary. PENALTY None 12. I request a hearing before an Administrative Law Judge regarding the decision of the County Department of Human Services. Following are my reasons for requesting a hearing Name of County By signing this form I acknowledge that I have read and understand the following rights and obligations Because I am asking for a hearing the DHS may postpone the proposed action until I have had a hearing and a decision is issued by an Administrative Law Examiner. If DHS proposed action is upheld I will be required to repay any additional benefits that I received because the proposed action was postponed* If I withdraw this hearing request or if I do not go to the hearing when it is scheduled I will be required to repay any additional benefits that I received because the proposed action was postponed I DO DO NOT want to continue receiving the amount of food assistance I now receive until after my hearing. .

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