Document Actions
Request for a Fair Hearing
Please print this form, fill it out, and mail it to us.
| To: |
Human Services Board 120 State Street Montpelier, VT 05620-4301 |
|---|---|
| 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): |
|
