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Request for a Fair Hearing

Please print this form, fill it out, and mail it to us.

To:

Human Services Board

14-16 Baldwin Street, 2nd. Floor

Montpelier, VT  05633-4302

From:

 

 

 

Date:
 


 


 


 

The following individual requests a Fair Hearing:

Name and Social Security # of Petitioner:

 

 

 

Address:

 

 

 

Telephone Number:

 

 

Program:

 

 

i.e.Food Stamps, Medicaid, Mental Health, Office of Child Support
Action:

 

 

 

 

What happened? (denial, termination, delay)
Reason:

 

 

 

 

Why? (denied due to too much income)
Petitioner's Representative(s):