Instructions For Completing DHS-121

INSTRUCTIONS FOR COMPLETING DHS-121

This form is used by both the client and the agency representative to:

    1. Identify in writing by the client the cause of his/her appeal; and

    2. Identify, by the agency representative, the policy on which the decision causing the appeal was based.

 

The client receives this form at the time of notification of an Agency decision.

For Supplemental Nutrition Assistance Program (SNAP): A client has 90 days from the mail date of the Notice of Agency Action to request a hearing.
For General Public Assistance (GPA): A client has 10 days from the mail date of the Notice of Agency Action to request a hearing.
For All Other Programs: A client has 30 days from the mail date of the Notice of Agency Action to request a hearing.

Sections I and II

These two sections can be filled out by the client alone, or by the client and agency representative, if the client needs help in completing the form. The person requesting an appeal signs this section and returns the completed form to the appropriate regional or district office.

Section III

After Sections I and II are completed, the agency representative completes Section III, citing the agency policy(ies) with reference to the particular manual section(s) that was the basis for making the decision. This section is signed by the agency representative and supervisor. The area identifying the local office is completed. The form is routed promptly to the hearing office at Central Office.

NOTE: When the DHS-121 is completed by the client and mailed directly to Central Office, without being routed through the regional or district office, the hearing office makes a copy of the DHS-121. The original is sent to the regional or district office for completion of Section III. The DHS-121 must be returned to the hearing office at Central Office within seven (7) days.

Legal Help

At the scheduled hearing, you may represent yourself, or be represented by someone else such as a lawyer, a relative, a friend, or another person. If you want free legal help, call Rhode Island Legal Services at 274-2652 (outside the Providence calling area, call toll free at 1-800-662-5034).

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