Pennsylvania Public Benefits Fair Hearing / Appeal Request Template

Templates are for informational purposes only and do not constitute legal advice. This is a court-functional agency appeal template for Pennsylvania public benefits matters.

FAIR HEARING / APPEAL REQUEST

To: Pennsylvania Department of Human Services / County Assistance Office

Program: [SNAP / Medical Assistance / TANF / LIHEAP / Unemployment Compensation / Other]

County: [COUNTY] County

County Assistance Office: [CAO NAME]

Applicant / Recipient Information

Name: [FULL LEGAL NAME]

Date of Birth: [DATE OF BIRTH]

Record Number / Case Number: [CASE NUMBER]

COMPASS Application or Renewal Number: [NUMBER, IF ANY]

Mailing Address: [STREET ADDRESS, CITY, PA ZIP]

Phone: [PHONE NUMBER]

Email: [EMAIL ADDRESS]

Agency Action Being Appealed

I request a fair hearing because I disagree with the action checked below:

• [ ] Denial of benefits
• [ ] Termination of benefits
• [ ] Reduction of benefits
• [ ] Delay in processing application or renewal
• [ ] Overpayment / recoupment determination
• [ ] Sanction or work requirement decision
• [ ] Failure to provide required notice
• [ ] Unemployment Compensation determination
• [ ] Other: [DESCRIBE]

Date on notice: [DATE ON NOTICE]

Date received: [DATE RECEIVED]

Benefit program involved: [PROGRAM NAME]

Statement of Disagreement

I disagree with the decision for these reasons:

1. [EXPLAIN WHY THE DECISION IS WRONG]
2. [IDENTIFY DOCUMENTS OR FACTS THE AGENCY DID NOT CONSIDER]
3. [DESCRIBE HOUSEHOLD, INCOME, DISABILITY, MEDICAL NEED, SHELTER COST, OR OTHER FACTS]

Continued Benefits Request, If Applicable

• [ ] I request continued benefits while this appeal is pending, if available under the program rules and if this request is timely.

Accommodation / Interpreter Request

• [ ] I need an interpreter in: [LANGUAGE]
• [ ] I request a disability accommodation: [DESCRIBE]
• [ ] I request a telephone or remote hearing if available.

Documents Attached

• [ ] Agency notice
• [ ] COMPASS application / renewal confirmation
• [ ] Pay stubs or income proof
• [ ] Rent, mortgage, utility, or shelter-cost proof
• [ ] Medical records or disability proof
• [ ] Immigration or identity documents
• [ ] Correspondence with the agency
• [ ] Other: [LIST]

Relief Requested

I request that the agency action be reversed or corrected, that eligible benefits be approved, restored, recalculated, or continued as appropriate, and that all attached documents be considered.

VERIFICATION UNDER 18 Pa.C.S. § 4904

I verify that the statements made in this request are true and correct to the best of my knowledge, information, and belief. I understand that false statements made herein are subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.

Date: _______________

Signature: ______________________________

Printed Name: [FULL LEGAL NAME]

Filing / Submission Instructions

1. Keep a copy of the notice and this request.
2. Submit through COMPASS, by mail, fax, in person, or by the method listed on the notice.
3. Ask for a receipt, fax confirmation, upload confirmation, or certified mail receipt.
4. If benefits are being reduced or terminated, submit immediately and ask whether continued benefits are available pending appeal.
5. Bring all documents, notices, proof of submission, and witnesses to the hearing.

Authority and Source Notes

• 7 U.S.C. § 2011 et seq. — Supplemental Nutrition Assistance Program.
• 42 U.S.C. § 1396 et seq. — Medicaid.
• 42 U.S.C. § 601 et seq. — TANF.
• 62 Pa.C.S. § 101 et seq. — Pennsylvania public welfare framework.
• 62 Pa.C.S. § 431 et seq. — Medical Assistance.
• 55 Pa. Code Chapter 275 — Public assistance appeal and fair hearing regulations.
• 55 Pa. Code Chapter 255 — SNAP-related regulations.
• 55 Pa. Code Chapter 225 — TANF-related regulations.
• 18 Pa.C.S. § 4904 — Unsworn falsification to authorities.

Jurist-Diction is not a law firm. This template provides jurisdiction-specific legal information and a court-ready document structure for public benefits appeals. Does not constitute legal advice.