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Independent Living Program - Florida's Center for Child Welfare

Independent Living Program - Florida's Center for Child Welfare

Independent Living Program - Florida's Center for Child Welfare

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whose name is_____________________ and number is_________.Sincerely,_______________Name and TitleAttachments: “Your Rights to Due Process” BrochureREQUEST FOR FAIR HEARING <strong>for</strong>m[Attachment F](a) <strong>Independent</strong> <strong>Living</strong> Fair Hearing RequestA hearing has been requested <strong>for</strong>:____________________________________Name____________________________________Address____________________________________City, State Zip______________/______________________Telephone Number / Social Security NumberThe Authorized Representative (if applicable) is:____________________________________Name____________________________________Address____________________________________City, State Zip____________________________________Telephone NumberThe [CBC/Department] has taken the following action regarding the individual’s eligibility <strong>for</strong> or receipt of <strong>Independent</strong> <strong>Living</strong>benefits from the Department through its contracted CBC:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The individual has stated that he/she is not satisfied with this action and is requesting a hearing <strong>for</strong> the following reasons:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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