Form DPA 19 at a glance
What it is: DPA 19 is the Authorized Representative form: if you want to authorize someone to represent you at the hearing, complete this form.
Who signs: You sign to authorize your department to release any or all information relating to this request to this person/organization.
A filled-in Form DPA 19 example: an appellant authorizes a representative
How to fill out Form DPA 19, box by box
Your name and address
After I, write your Name, then your Address and your City, State and Zip.
Your representative
After have requested, write the Name, Organization, Address and City and Zip of your representative.
Assistance Program
Your representative is to act on your behalf in your appeal regarding your application for and/or receipt of the Assistance Program you write.
Signed
Sign on the Signed line.
More rules for Form DPA 19
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.
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.
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.
Common questions about Form DPA 19
Where do I file it?
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.
Sources
[1] Form DPA 19 (12/10), Authorized Representative, California Department of Social Services (the Official source link on this page).