REQUEST FOR HEARING

NORTH DAKOTA DEPARTMENT OF HEALTH AND HUMAN SERVICES
LEGAL DIVISION
SFN 162 (5-2023)

This process is available to appeal an adverse determination made by the Department of Health and Human Services.
Click here to review the Rights to Hearing
Rights to a Hearing confirmation *
By checking this box you are confirming you have read and understand the "Rights to a Hearing " information.
I am appealing a decision made by:
Program Name
APPEAL OF:
Name * First Last
Phone - ### - ### ####
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
STEP 1: ATTACH THE NOTICE THAT YOU ARE CONTESTING.
* Accepted file types include pdf, tif, tiff, jpg, jpeg
* Max of 5 files
* Each file must not exceed 10 MB in size

Attach Files Attach Files
STEP 2: EXPLAIN THE ERROR THAT YOU CLAIM WAS MADE. *
Maximum of 1300 characters allowed. Currently Entered: 0 characters.
Check here if you need addition space to explain the error
Maximum of 1300 characters allowed. Currently Entered: 0 characters.
STEP 3: FOR RECIPIENTS APPEALING ECONOMIC ASSISTANCE BENEFITS:
I want to continue receiving benefits at the previous benefit level.
I understand that I may continue to receive benefits pending the outcome of the fair hearing. However, if the fair hearing official's decision is not in my favor, all adult members in my household will be held liable for any overissuances received while awaiting the outcome of the fair hearing. Applicants who are denied benefits at initial certification or because of the expiration of their certification may appeal the denial, but cannot receive benefits while awaiting the outcome of the hearing.
I do not want to continue receiving benefits at the previous benefit level.
STEP 4: Complete this part only if you will have someone such as an attorney, relative or other person of your choosing, assist you in your appeal.
By checking this box I am authorizing the person listed below to assist me with my Appeal.
Authorized Person Infomation:
Name First Last
Phone - ### - ### ####
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
STEP 5: SIGN AND DATE
By signing my name, I attest that I have read and understand my rights.
Typed Signature
Date

REQUEST FOR HEARING

REQUEST FOR HEARING

This process is available to appeal an adverse determination made by the Department of Health and Human Services.

Click here to review the Rights to Hearing

I am appealing a decision made by:

APPEAL OF:

Authorized Person Infomation:

STEP 5: SIGN AND DATE

By signing my name, I attest that I have read and understand my rights.