Form Pa Fs 162A PDF Details

Navigating the complexities of benefit adjustments can be challenging for individuals relying on assistance programs. The Pa FS 162A form serves as a critical tool in this process, providing recipients with advance notice of any planned changes to their benefits, including discontinuation, reduction, or suspension. This form covers a range of programs such as assistance checks, social services, food stamps, medical assistance, and nursing home care, detailing the type and extent of changes alongside the specific starting dates. Moreover, it outlines the reason for these adjustments, referencing the relevant regulations and reason codes. Recipients are informed about the considerations taken into account when determining their benefit amounts, including household composition, income, dependent care costs, and shelter expenses. Importantly, the document also explains the rights of recipients to appeal these decisions, offering a pathway to request a hearing and potentially contest the changes made to their benefits. This ensures individuals are not only aware of how their assistance might change but also understand their rights to challenge these decisions if they believe them to be incorrect or unjust.

QuestionAnswer
Form NameForm Pa Fs 162A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespa fs 162 form, pa fs 162, fs pa 162, Washington

Form Preview Example

 

 

 

 

 

 

ADVANCE NOTICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS IS TO NOTIFYYOU THAT THIS OFFICE HAS DECIDED TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REDUCE

 

 

DISCONTINUE

 

 

 

SUSPEND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR BENEFITSHOWN BELOW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BENEFIT

 

 

 

 

 

 

 

 

 

 

 

 

 

BENEFIT

 

BEGINNING

 

TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BEGINNING

FROM

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

ASSISTANCE CHECK

 

 

 

$

 

 

 

$

 

 

 

 

 

SOCIALSERVICES

 

 

 

 

 

 

 

 

FOOD STAMPS

 

 

 

$

 

 

 

$

 

 

 

 

 

MEDICALASSISTANCE

 

 

 

 

 

 

 

 

NURSING HOME CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your level of care has been changed

 

 

 

 

 

 

 

 

 

 

OTHER (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your patient pay amount was changed

$

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WE PLAN TO TAKE THIS ACTION BECAUSE OF THE FOLLOWING FACTS AND REGULATIONS

Regulation

Reason Code

THE FOLLOWING ITEMS WERE TAKEN INTO CONSIDERATION IN DETERMINING THE AMOUNT OF YOUR BENEFITS

FOODSTAMPS

Number of Persons

ASSISTANCECHECK

Number of Persons

Name

 

GROSS MONTHLY

Name

 

GROSS MONTHLY

 

EARNED INCOME

 

EARNED INCOME

 

 

$

 

 

$

 

 

 

$

 

 

$

 

 

 

$

 

 

$

 

Name

 

GROSS MONTHLY

Name

 

GROSS MONTHLY

 

UNEARNED INCOME

 

UNEARNED INCOME

 

 

$

 

 

$

 

 

 

$

 

 

$

 

 

 

$

 

 

$

 

TOTALGROSS MONTHLYINCOME

 

$

TOTALGROSS MONTHLYINCOME

 

$

 

GROSS MONTHLYDEPENDENT CARE COSTS

$

GROSS MONTHLYDEPENDENT CARE COSTS

$

 

GROSS MEDICALCOSTS

 

$

 

 

 

 

Telephone

Water/Sewage

MEDICALASSISTANCE

Number of Persons

Electric

Garbage/Trash

Name

 

GROSS MONTHLY

 

EARNED INCOME

Gas

Utility Installation

 

 

$

 

Oil

Other

 

 

 

$

 

GROSS UTILITYCOSTS/UTILITYSTANDARD*

$

 

 

$

 

RENT/MORTGAGE

 

$

Name

 

GROSS MONTHLY

 

 

UNEARNED INCOME

TAXES

 

$

 

 

$

 

INSURANCE COST ON HOME

 

$

 

 

$

 

TOTALSHELTER COST

 

$

 

 

$

 

 

 

 

TOTALGROSS MONTHLYINCOME

 

 

$

 

 

 

NET MONTHLYINCOME/NET SEMI-ANNUALINCOME

$

 

 

 

INCOME LIMIT

 

 

$

COMMENTS:

 

 

APPEALAND FAIR HEARING

 

 

 

 

 

 

 

 

Worker’s Signature

 

 

Mailing Date

 

 

 

 

 

 

 

CO

RECORD NUMBER

CAT

CTRDIG

DIST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you disagree with our decision, you have the right to appeal. See reverse for a complete explanation of your right to appeal and to a fair hearing.

TelephoneNumber

If your oral request for a hearing is received in the County

 

 

 

 

 

 

 

 

Assistance Office or your written request is postmarked or

 

 

 

 

received on or before

 

 

 

your assistance will

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

continue pending the hearing decision, except when the change

 

 

 

 

is due to State or Federal Law.

 

 

 

 

 

 

 

 

 

 

 

 

Check here if you do not want your food stamps to continue

 

 

 

 

 

 

 

 

 

 

 

 

at the current amount pending the hearing decision.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEGALHELPIS AVAILABLE AT

If you do not request a hearing before the date shown above, we will assume that our facts are correct and the proposed action will be taken. If you do not understand our decisionorhaveanyquestions,contactyourworker.

CLIENT

APPEALCOPY

CASE RECORD COPY

PA/FS 162A 4/08

YOUR RIGHT TO APPEALAND TO AFAIR HEARING

You have the right to appeal any Departmental action or failure to act and to have a hearing if you are dissatisfied with any decision to refuse, discontinue, change, suspend, or reduce assistance or food stamps. However, if a change in your ASSISTANCE CHECK, SOCIAL SERVICES, or MEDICALASSISTANCE is caused by State or Federal law requiring mass grant adjustment for classes of recipients, you will not be granted a hearing unless you are appealing the correctness of your grant computation. If you are only challenging the law, your appeal will be dismissed by the Department but may be appealed to a higher court.

At the hearing you can present to the Hearing Officer the reasons why you think the decision of the County Assistance Office is incorrect and present evidenceorwitnessesinyourownbehalf. Youhavetheright torepresentyourselfortohaveanyonerepresentyou. AstaffmemberoftheCountyAssistance Office will refer you for free legal help upon request.

If you need an interpreter at the hearing because you do not speak English or you have limited understanding of English, or you have a hearing impairment, the Department will arrange for an official interpreter at no cost to you. You may bring a friend or relative to assist you at the hearing, but the interpreter provided by the Department will be the official interpreter. If you require any reasonable or special accommodation because of a hearing impairment (or other disability), the necessary arrangements will be made to provide the accommodation. You must make the request for an interpreter or other accommodation in advance of the hearing.

If you and your representative would like to meet with County Assistance Office staff to discuss the matter informally or to present information which might change the proposed action, please call your worker. This will not delay or replace your fair hearing.

If the decision affects your ASSISTANCE CHECK, SOCIALSERVICES, or MEDICALASSISTANCE, your request for a hearing must be postmarked or received within 30 days of the mailing date of this notice. If your oral or written request is postmarked or received within 10 days of the mailing date of this notice, your benefits will continue pending the outcome of the hearing. If your benefits are continued and the decision is in favor of the CountyAssistance Office, any assistance you received from the date the action would have been effective to the date the hearing order is implemented must be paid back to the Department. If your request is not postmarked or received within the 30-day time limit, your appeal will be dismissed without a hearing.

If this decision affects your FOOD STAMPS, your request for a hearing must be postmarked or received within 90 days from the beginning date of the change of the benefits. If your oral or written request is postmarked or received within 10 days of the mailing date of this notice, your food stamps will continue at the current amount pending the hearing decision or the end of your eligibility period, whichever comes first. If you do not want your food stamps to continue at the current amount, check the box on the reverse side. If your food stamps are continued and the decision is in favor of the CountyAssistance Office, the value of the extra food stamps you received must be paid back to the Department. If your request is not postmarked or received within the 90-day time limit, your appeal will be dismissed without a hearing.

HOW TO REQUEST AFAIR HEARING:

To appeal and request a hearing for ASSISTANCE CHECKS, MEDICALASSISTANCE or SOCIAL SERVICES, you may call your worker; but, you must also put the appeal in writing as follows: (1) Fill out and sign one copy of this form. Give the reason for your appeal; and Give your telephone number; and Give your exact address; and (2) Mail or take this form to the CAO at the address on the front side of this form. To appeal and request a hearing for FOOD STAMPS, you may call your worker; or put the appeal in writing; or do both. If you put the appeal in writing, follow the instructions above.

PLEASE CHECK THE BOX NEXTTO THE TYPE OF HEARING YOU WANT:

I want a Telephone Hearing. I and my witnesses and anyone helping me will be at this phone number: _______________________________.

I want a Telephone Hearing. I and my witnesses and anyone helping me will be at the County Assistance Office (CAO).

I want a Face-to-Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge and the caseworker and CAO staff.

I want a Face-to-Face Hearing. I and my witnesses and anyone helping me will be in the hearing room with the Judge. The caseworker and other staff will be on the phone from the CAO, if they decide not to come to the hearing room.

PLEASE CHECK BELOW IF YOU NEED HELPBECAUSE OF AHEARING PROBLEM OR DISABILITYOR YOU NEED AN INTERPRETER:

I have a hearing impairment or disability. I will need special help.

I need an interpreter. There will be no cost to me. What language? _______________________________

I WANT TO REQUEST AHEARING BECAUSE:

DATE

CLIENTREPRESENTATIVE SIGNATURE

TELEPHONE #

DATE

CLIENTSIGNATURE

TELEPHONE #

CLIENTADDRESS

 

 

HEARING LOCATIONS

 

 

 

 

 

PHILADELPHIAFOR:

Bucks, Chester, Delaware, Montgomery, Philadelphia.

PITTSBURGH FOR:

Allegheny, Armstrong, Beaver, Bedford, Blair,Butler, Cambria, Cameron, Clarion,Clearfield, Crawford, Elk, Erie, Fayette,

 

Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango,Warren,Washington,Westmoreland.

HARRISBURG FOR:

Adams,Berks, Centre, Cumberland,Dauphin,Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Lycoming, Mifflin,

 

Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, York, Lehigh.

PLYMOUTH FOR:

Bradford, Clinton, Lackawanna, Monroe,Sullivan, Tioga, Wyoming, Carbon, Columbia, Luzerne, Pike, Susquehanna, Wayne.

CLIENT

APPEALCOPY

CASE RECORD COPY

PA/FS 162A 4/08

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CAO writing process clarified (portion 1)

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