REQUEST FOR ADMINISTRATIVE HEARING

Date: _______________________________________________________________

Name: ______________________________________________________________

Address: ____________________________________________________________

Representative: ______________________________________________________

Address: ____________________________________________________________

I request an administrative hearing to review the decision or final action taken by:

Worker/Employee/Agent: ______________________________________________

SRS Office: _________________________________________________________

Type of Program: ____________________________________________________

Date of Action Being Appealed: ________________________________________

I am requesting consideration of this matter because: (continue on attached page if necessary)

(Explain why decision or final action is not satisfactory in your circumstances)

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

I understand that this is a hearing before an impartial Presiding Officer of the Office of Administrative Hearings, Department of Administration.

 

 

________________________________________         
 Signature (Person requesting the hearing)             

FOR FOOD STAMPS ONLY:

 

Until the Hearing: (Check one)

 

_____ I want to continue receiving the amount of food stamps I currently receive.

_____ I do not want to continue receiving the amount of food stamps I currently receive.

I UNDERSTAND THAT IF THE HEARING RESULTS SHOW THE ACTION WAS CORRECT, I OWE THE VALUE OF THE EXTRA FOOD STAMPS I RECEIVED WHILE AWAITING THE DECISION.

 

________________________________________         
 Signature (Person requesting the hearing)             

Office of Administrative Hearings

Department of Administration

RULES AND REGULATIONS

RELATING TO SRS FAIR HEARINGS

  1. K.S.A. 75-3306, as amended, provides that "The secretary ... shall provide a fair hearing for any person ... who appeals from the decision or final action of any agent or employee of the secretary". The hearing shall be conducted in accordance with the provisions of the Kansas administrative procedure act, 77-501 et. seq.
  2. A dissatisfied individual or entity must request an administrative hearing in writing and sign it (except for food stamps where the request may be oral). This form may be used but it is not a requirement. The request for an administrative hearing must be signed and returned to the local agency office or sent to the Office of Administrative Hearings, 1020 S Kansas Avenue,Topeka, Kansas 66612-1327. The individual or entity requesting the administrative hearing shall then be called an appellant and the party whose decision is appealed shall be called the respondent.
  3. Written notice of the time and place of the hearing shall be given by the Office of Administrative Hearings to the appellant and to the respondent at least ten days prior to the hearing.
  4. The appellant may have a representative of his/her own choice and witnesses and produce documentary evidence relating to his/her appeal. The hearing shall be attended only by persons directly connected with the issues involved or those designated by the appellant and the respondent. Failure to participate in the scheduled hearing may result in your appeal being dismissed.
  5. The hearing shall be conducted by a Presiding Officer from the Office of Administrative Hearings, Department of Administration. (K.S.A. 75-37,121)
  6. A recording shall be made of the hearing, and this recording shall be reduced to a transcript if requested for good cause shown by any of the parties to the hearing.
  7. A copy of the initial order of the Presiding Officer shall be mailed to the appellant, the respondent, and to the local agency office if it is to have a part in the implementation of the decision.
  8. A request for administrative hearing shall be in writing and signed (except in food stamps where the request may be oral) and received by the agency within 30 days from the date of the order or notice of action.
  9. If an individual is in need of any special accommodation, in order to be involved in the hearing, they should notify the Office of Administrative Hearings, 1020 S. Kansas Ave., Topeka, KS  66612.