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Click ‘Get Form’ to open Appeal - Form 1 in the editor.
Begin by filling out Part 1: General Information. Enter your name, date of birth, address, and contact details. Ensure accuracy as this information is crucial for your appeal.
In Part 2: Internal Review Information, provide the date of your original Notice of Decision and the date you requested an internal review. Indicate whether you received an internal review decision.
Move to Part 3: Your Appeal. Check all applicable reasons for your appeal and provide a detailed explanation of why you disagree with the original decision.
For Part 4: Your Hearing, enter your email address for scheduling purposes and specify any accommodations needed for the hearing.
If applicable, complete Part 5: Application for Interim Assistance by detailing your household situation and financial circumstances.
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