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I want to stop getting benefits until the appeal decision. If you file an appeal within 10 days of the agency action your benefits may continue if you do not check one of the boxes. Signature CLIENT SIGNATURE DATE Note If you need help completing this form or want to discuss your appeal with someone you may contact a private attorney or the legal services office that serves your agency. DHS-0033-ENG Appeal to State Agency Client information NAME OF AGENCY CASE NUMBER NAME OF PROGRAM S NAME TELE ...

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