{Date}

CLAIM Form Letter

Dear,

Your household no longer qualifies to receive Food Distribution benefits from our agency, effective date: . The reason for this action is explained in the checked box(s) marked below:

This change is being made because:

OVER-INCOME DUE TO:

  • New Income Source or Wage Raise Increase in the month of ______
  • Other (explain):

State records indicate a member of your household: ___ is now receiving benefits from the Supplemental Nutrition Assistance Program (SNAP, a.k.a. food stamps).

Your household was ineligible for food distribution benefits in yetaccepted and received an over-issuance of food benefits for which it was ineligible. Your household will remain ineligible for future food distribution benefits, effective (date)\. A monetary claim is being assessed against your household to repay the program in the amount of (specify dollar amount $0.00) for the foods for which it was over-issued.

You should make every effort to pay the full amount you owe. If you cannot pay the full amount now, we can arrange for installment payments. All payments are to be made payable by money order to “FNS” and mailed to:

USDA-FNS-HQ
P.O. Box 953807
St. Louis, MO 63195-3807.

It is important that you pay this claim or explain why you cannot pay. You can request a fair hearing of your case if you do not agree with our decision. To request a fair hearing you can call the same number above or fill out the attached form and return it to the tribal administrator who you turned your food distribution application in to.

Sincerely,

{Name Agency Administrator}

{Tribal Agency Name}

cc: file

Attachments: Food Value List (# pages)

Fair Hearing Procedures & Request Form (FDP011)

USDA NON-DISCRIMINATION STATEMENT

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, religious creed, disability, age, political beliefs, 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: 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: .

This institution is an equal opportunity provider.

FAIR HEARING PROCEDURES

These Fair Hearing Procedures have been prepared so that:

  1. Applicants/recipients to the Food Distribution Program may know their rights to a fair hearing.
  2. Food Distribution Agency staff may acquaint themselves with the fair hearing standards.

If you are a recipient or applicant to the Food Distribution Program and you believe you have been aggrieved, you may ask your eligibility worker for a fair hearing or you may contact the Tribal Administrator at {insert your tribe’s name here} to request a fair hearing.

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Request

Every household has a right to request a Fair Hearing at any time it believes it has been aggrieved by some action of the Food Distribution Agency. At the Fair Hearing, an impartial third party will review the action. A copy of a request form is attached.

Time Line for Request

A household has the right to request a fair hearing on any action by the agency, which occurred in the past ninety days.

Dismissing a Request

The Agency shall not deny or dismiss a request for a fair hearing unless:

  1. The request is not received within ninety days;
  2. The request is withdrawn in writing by the household or its representative;
  3. The household or its representative fails without good cause to appear at the scheduled meeting.

Continuation of Benefits

If a household asks for a fair hearing within the period provided by the Notice of Adverse action the household has the right to continue to receive food benefits while the Fair Hearing is pending and until the hearing decision is made. If the outcome of the fair hearing and decision is found to unfavorable to the household the household will be liable for the dollar amount of food benefits that it received, while awaiting the final decision and will a claim will be filed for the household to repay the dollar value of the food benefits it received.

Discontinuation of Benefits

If household requests a fair hearing after the period provided by the Notice of Adverse action the households food benefits will be reduced or terminated as provided in the notice unless the household’s failure to make a request within the advance notice period was for good cause.

Notification of Reduction or Termination

The Agency shall promptly inform the household in writing if benefits are reduced or terminated pending the hearing decision.

Exceptions

If a household is granted continued benefits pending the hearing decision, benefits shall not be reduced or terminated prior to the official hearing decision unless:

  1. The hearing official makes a preliminary determination, in writing and at the hearing, that the sole issue is one of the Federal law or regulation and that the household’s claim is that the agency misapplied such law or regulation is invalid;
  2. A change affecting the household’s eligibility or level of benefits occurs while the hearing decision is pending and the household fails to request a hearing after the subsequent notice of adverse action.

Action Time Line

Within sixty days after a household requests a fair hearing, the Agency shall conduct the hearing, arrive at a decision, and notify the household and local agency of the decision.

Postponement

A household has the right to request a postponement of the hearing, not to exceed 30 days. The time limit for action on the hearing may be extended for as many days as the hearing is postponed.

Immediate Resolution Agency Conference

A household has the right to ask for an immediate resolution of a denial of eligibility for food benefits by way of an agency conference. The agency may also offer an agency conference to a household adversely affected by the agency action.

The agency conference is optional and shall in no way delay or replace the fair hearing process if there is no resolution of the disputed action. For households requesting an agency conference for immediate resolution, the conference shall be scheduled within four (4) working days unless the household requests otherwise.

Agency Assistance

A household has the right to request the agency to make available without charge the specific material necessary for a household or its representative to determine whether a hearing should be requested or to prepare for a hearing.

Legal Services

The agency shall advise a household of any legal services that can provide representation at the hearing.

Advance Notice

At least 15 days prior to the hearing the Agency shall provide advance written notice to all parties involved regarding the time, date, and place of hearing. The household has the right to request less advance notice to expedite the scheduling of the hearing.

The notice shall contain the following:

  1. The name, address, and telephone number of the person to notify in the event it is not possible for the household to attend the meeting;
  2. Advise the household that the Agency will dismiss the hearing request if the household or its representative fails to appear for the hearing without good cause;
  3. Hearing procedures and any other information that would provide the household with an understanding of the preceding and would contribute to the effective presentation of the household’s case;
  4. Explain that the household or its representative may examine the case prior to the hearing.

Household Rights at Hearing

The household may not be familiar with the rules of order and it may be necessary to make particular efforts to arrive at the facts of the case in a way that makes the household feel most at ease. The household or its representatives have the following rights during the hearing process:

  1. Examine Documents

The household or its representative must be given adequate opportunity to examine all documents and records to be used at the hearing at a reasonable time before the date of the hearing as well as during the hearing. However, confidential information, such as names of individuals who have disclosed information about the household without its knowledge or the nature or status of pending criminal prosecutions shall be protected from release. If requested by the household or its representative the State Agency shall provide a free copy of the relevant portion of the case file. Confidential information that is protected from release and otherwise have an opportunity to contest or challenge shall not be presented at the hearing or affect the hearing official’s decision.

  1. Present Case

The household may present the case itself or have it presented by a legal counsel or other person.

  1. Bring Witnesses

The household or its representative may bring witnesses to support its case in the appeal.

  1. Advance Arguments

The household or its representative shall be allowed to advance arguments without undue interference.

  1. Submit Evidence

The household or its representative may submit evidence to establish all pertinent facts and circumstances in the case.

Hearing

A representative of the agency and of the local agency that initiated the action being contested and by the household or its representative or both shall attend the hearing. Friends or relatives of the household may also attend if space permits.

Hearing Decision

The decision of the hearing authority shall comply with Federal Law or regulations and shall be based on the hearing record. The decision shall summarize the facts of the case, specify the reasons for the decision, and identify the supporting evidence and the pertinent Federal regulations. The decision shall become part of the record. An official report containing the substance of what transpired at the hearing, together with all papers and requests filed in the proceeding shall constitute the exclusive record for the final decision.

Notification of Decision

The household and the local agency shall each be notified in writing of the decision, the reasons, the available appeal rights and that the household’s benefits will be issued or terminated as decided by the hearing authority.

Appeal

The household has the right to appeal an adverse fair hearing decision through the pursuit of judicial review.

Civil Rights

You have the right to be treated with courtesy and respect without regard to sex, race, color, age, political beliefs, religion, handicap, or national origin.

For further information on the Fair Hearing Rules, refer to the FNS Handbook 501, Section 5, Fair Hearing. You may obtain a copy of the FNS Handbook 501 from the local Food Distribution Program office.

REQUEST FOR FAIR HEARING

You can have a fair hearing of your case if you don’t agree with our decision. At the hearing you will have a chance to explain why you disagree. A hearing officer will decide who is right. To request a hearing, please call the Food Distribution office at 907-729-2975 or complete the form below and return to our office. You can continue to receive commodities at your current rate if you request a hearing by ______. You can receive them until your hearing is decided. If the hearing finds that our decision was correct your household will owe USDA the value of the extra commodities you received. You can still request a hearing after the date above but you won’t be able to receive food distribution at your current rate. If you want to discuss our decision or ask any questions about a fair hearing call the office.

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______

NAME OF PERSON REQUESTING A HEARING TELEPHONE NUMBER

______

ADDRESS CITY, STATE, & ZIP CODE

______

SIGNATURE AND DATE

Please submit this written statement to request for a Fair Hearing.

FOR OFFICE USE ONLY: ______

CASE NUMBER DATE REQUEST RECEIVED

IF YOU WOULD LIKE TO CONTINUE TO RECEIVE COMMODITIES, PLEASE MARK THIS BOX  AND RETURN TO OUR OFFICE.