DP 19 Form PDF Details

When navigating the complexities of receiving assistance in California, individuals may find themselves in situations where they need to appeal decisions made regarding their applications. This is where the DPA 19 form comes into play. Issued by the State of California's Department of Social Services, this crucial document serves as an authorization for an individual to appoint a representative to act on their behalf during the appeals process. Whether it's due to an application for or receipt of assistance from various programs, the form facilitates communication and information sharing between the person appealing and the Department of Social Services. By completing this document, individuals ensure that their chosen representatives can fully participate in the appeal process, including attending hearings and obtaining necessary information to support the case. Additionally, the DPA 19 form outlines the importance of either attending the hearing in person or making sure the appointed representative does so. It emphasizes that failing to appear can lead to the dismissal of the appeal. Furthermore, the form acknowledges the significance of bringing any evidence or witnesses that could bolster the case. With clear instructions on how to use this form and its role in the hearing process, understanding the DPA 19 form is essential for anyone looking to navigate the appeals process effectively and ensure their rights are adequately represented.

QuestionAnswer
Form Name DP 19 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names Administrative, DPA, continuance, dpa 19

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

AUTHORIZED REPRESENTATIVE

, 20

State of California

Department of Social Services

P.O. Box 944243, M.S. 9-17-37

Sacramento, California 94244-2430

I,

 

 

 

 

of

 

 

(Name)

 

 

 

 

 

 

(Address)

 

 

(City, State and Zip)

have requested

(Name)

(Organization)

(Address)

(City and Zip)

to act on my behalf in my appeal regarding my application for and/or receipt of

(Assistance Program)

I hereby authorize your department to release any or all information relating to this request to this person/organization.

Signed

DPA 19 (12/10)

PAGE 1 OF 2

IF YOU STILL WANT YOUR HEARING, it is required that you attend the hearing or have someone appear on your behalf. If no such appearance is made at the time scheduled, the entire matter will be dismissed. Even though you appoint someone to represent you, your appearance at the hearing would be helpful to the Administrative Law Judge in arriving at an appropriate decision. If you have authorized someone to act as your representative, that authorization should be in writing, and given to the Administrative Law Judge at the hearing. This Authorized Representative form is enclosed for this purpose. If you want to authorize someone to represent you at the hearing, please complete this form and either bring it to your hearing or have your representative bring it to the hearing on your behalf. You should notify your representative of the time and place of your hearing. You may bring witnesses or other persons who you believe can help you explain your position. You should also bring any documents or other papers that you think important and that you wish to have considered.

Information regarding your request has been sent to your county welfare department or to the California Department of Health Services. Staff from that agency may be contacting you about the agency's decision, the reason for its action, and the reasons for your request in an effort to resolve the problem.

If you have been receiving assistance, your assistance will continue in the same amount if your request was filed before the effective date of the proposed action and you requested continuance of your aid pending.

If you are not now receiving assistance, you will not receive aid pending your state hearing.

DPA 19 (12/10)

PAGE 2 OF 2

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1. For starters, once filling in the relating, start in the section with the next fields:

dpa 19 form writing process shown (portion 1)

2. The third stage is usually to complete these particular fields: I hereby authorize your department, Assistance Program, and Signed.

dpa 19 form conclusion process described (part 2)

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