OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE OFFICE OF ADMINISTRATIVE HEARINGS
Website: www.otda.state.ny.us/oah FAX to: (518) 473-6735
Telephone #: 1-800-342-3334
FAIR HEARING REQUEST FORM – FAX OR MAIL
P.O. BOX 1930
ALBANY, NY 12201-1930
Please Print Information Clearly. Correct and Complete Information will Permit us to Promptly Schedule a Fair Hearing
CASE NAME: ___________________________________________ ________________________________________ ______________
(LAST) (FIRST) (MI)
STREET ADDRESS: ______________________________________________________________ APT. #: _________________________
CITY: __________________________________________ STATE: _____________ ZIP CODE: ______________________________
DATE OF
PHONE #: ( ) __________________________ BIRTH: _______________________ SS#: ______________________________
AREA CODE PHONE #
MALE FEMALE CASE #: ___________________ CIN #: ____________ LOCAL AGENCY/CENTER #: __________
INTERPRETER NEEDED? YES NO LANGUAGE: _____________________________________________
Is appellant homebound? Yes No If yes, provide medical documentation. Do not delay request to obtain medical. A phone
number for representative or requester is required if you don’t have a phone:
Representative Requester NAME: _____________________________________________________________________
ADDRESS: ______________________________________________________________________________________________________
CITY: ______________________ STATE: _____ ZIP CODE: _________ PHONE #: ( ) ___________________________
AREA CODE PHONE #
DID APPELLANT RECEIVE A NOTICE FROM THE LOCAL SOCIAL SERVICES DEPARTMENT? YES NO
(***** PLEASE ATTACH A COPY OF THE NOTICE WITH THIS FORM *****)
If Yes: Date of Notice: ______________ Effective Date: ______________ NOTICE #: _____________ RTI #: ________________
RESTRICTIONS LOCAL AGENCY ACTION CATEGORY OF ASSISTANCE (definitions below box)
Put an X in days or times FA SNA MA FS FAP PCS* OTHER (indicate
you cannot attend hearing what type)
M T W T F Discontinuance ___________
AM __ __ __ __ __ Reduction ___________
Denial ___________
PM __ __ __ __ __ Inadequacy ___________
(Must provide a reason) * If Personal Care Services: Provide CASA # ______/Agency _______ & indicate type of services: _________
FA=Family Assistance (formerly ADC) SNA=Safety Net Assistance (formerly HR) MA=Medicaid
FS=Food Stamps FAP=Food Assistance Program PCS=Personal Care Services
Reason for requesting hearing (indicate time frames): _____________________________________________________________________
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Information needed for Foster Care hearings: Child’s name, child’s date of birth, natural mother’s name, child’s case number, agency’s name.
Need to indicate period seeking foster care payments.
Revised 5/18/05 TODAY’S DATE _____________________________
