Child Care Service Appeal

DCC-88 922 KAR 1:320 (R. 11/09)

TO REQUEST AN ADMINISTRATIVE HEARING FOR APPEAL OF A CABINET CHILD CARE ATTENTION TO PERSONS WHO ARE ACTION, PLEASE COMPLETE NOT ELIGIBLE FOR AN THIS FORM Service ADMINISTRATIVE HEARING UNDER AND MAIL TO: THE SERVICE APPEAL PROCESS: Appeal

FOR RESOLUTION OF A MATTER Quality Assurance Section NOT SUBJECT TO REVIEW THROUGH 275 East Main Street, 1E-B In Accordance AN ADMINISTRATIVE HEARING, YOU Frankfort KY 40621 with 45 CFR 205.10 and MAY CONTACT THE OFFICE OF THE 922 KAR 1:320 OMBUDSMAN AT 1-800-372-2973. IF YOU NEED ASSISTANCE WITH IF YOU DO NOT WISH TO SPEAK COMPLETION OF THIS FORM, PLEASE CONTACT THE LOCAL OFFICE AT: CABINET FOR HEALTH WITH THE OFFICE OF THE OMBUDSMAN, YOU MAY SUBMIT AND FAMILY SERVICES YOUR COMPLAINT IN WRITING TO YOUR SERVICE AGENT NO LATER Department for Community THAN 30 DAYS FROM THE DATE OF Based Services THE ACTION TO WHICH YOU A REQUEST FOR AN 275 East Main Street OBJECT. ADMINISTRATIVE HEARING Frankfort KY 40621 SHALL BE MAILED WITHIN 30 DAYS FROM THE DATE OF A CABINET ACTION. FOR V/TDD SERVICES IF AVAILABLE, PLEASE SUBMIT A Call the CHFS Office of the COPY OF THE DCC 105, “CHILD Ombudsman CARE ASSISTANCE PROGRAM Toll Free at 1-800-627-4702 NOTICE OF ACTION” WITH THIS FORM.

KentuckyUnbridledSpirit.com An Equal Opportunity Employer M/F/D CHILD CARE SERVICE APPEAL

NAME OF COMPLAINANT (PLEASE PRINT): ______DATE: ______

ADDRESS: ______STREET/P.O. BOX NO. CITY STATE ZIP CODE

TELEPHONE NUMBER: ______COUNTY OF RESIDENCE: ______

PLEASE STATE IN DETAIL THE NATURE OF YOUR COMPLAINT AGAINST THE DEPARTMENT FOR COMMUNITY BASED SERVICES. (ADDITIONAL PAPER MAY BE USED IF NECESSARY.)

PLEASE IDENTIFY THE DATE OF THE DISPUTED CABINET ACTION: MONTH______DAY______YEAR______

PLEASE IDENTIFY EACH CABINET STAFF PERSON INVOLVED WITH THE SUBJECT MATTER OF YOUR APPEAL. (ADDITIONAL PAPER MAY BE USED IF NECESSARY.) Name: Title, if known: Work Address: City: County:

Name: Title, if known: Work Address: City: County:

CONTINUE YOUR BENEFITS? YOU MAY HAVE TO PAY BACK THESE BENEFITS IF THE DECISION IS NOT IN YOUR FAVOR. I WANT MY SAME BENEFITS CONTINUED UNTIL THE HEARING OFFICER MAKES A DECISION. CHECK YES _____ NO ______.

______SIGNATURE OF COMPLAINANT DATE SIGNATURE OF AUTHORIZED REPRESENTATIVE, IF APPROPRIATE DATE