Free WIC Notice of Ineligibility, DPH 40085 - Wisconsin


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State: Wisconsin
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DEPARTMENT OF HEALTH AND FAMILY SERVICES DPH 40085 (rev 05/06) Page 1 of 2

STATE OF WISCONSIN

WIC PROGRAM NOTICE OF INELIGIBILITY
This notice may be used for WIC Farmers' Market Nutrition Program (FMNP) purposes. Participation in WIC is voluntary. Personally identifiable information is used to determine WIC eligibility and may be disclosed to others only as allowed by state and federal laws.

Date: Guardian/participant name and address

Dear This letter is to notify you that is not eligible for WIC because:

Does not meet WIC income guidelines. Does not live in Wisconsin. Does not have a medical or nutrition problem. Is being suspended because of fraud or abuse. Is graduating from WIC; nutrition need has been resolved. Other

You have the right to appeal this decision by writing, phoning, or visiting the WIC Clinic before ______________ (60 days). If you ask for an appeal, a hearing will be scheduled to give you the chance to present your case. Your appeal rights are explained in an attachment to this letter. Please read them carefully. If you believe we have missed some important information about your eligibility, or if you wish to discuss this notice, please contact the WIC Clinic. If your situation has changed since you received this notice, please call to reapply. We hope you will use the other health services and please call us if you need information on nutrition.

WIC Project Name Address City, State, Zip Phone

In accordance with Federal law and U. S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.

DEPARTMENT OF HEALTH AND FAMILY SERVICES DPH 40085 (rev 05/06) Page 1 of 2

STATE OF WISCONSIN

WIC PROGRAM NOTICE OF INELIGIBILITY
This notice may be used for WIC Farmers' Market Nutrition Program (FMNP) purposes. Participation in WIC is voluntary. Personally identifiable information is used to determine WIC eligibility and may be disclosed to others only as allowed by state and federal laws.

Date: Guardian/participant name and address

Dear This letter is to notify you that is not eligible for WIC because:

Does not meet WIC income guidelines. Does not live in Wisconsin. Does not have a medical or nutrition problem. Is being suspended because of fraud or abuse. Is graduating from WIC; nutrition need has been resolved. Other

You have the right to appeal this decision by writing, phoning, or visiting the WIC Clinic before ______________ (60 days). If you ask for an appeal, a hearing will be scheduled to give you the chance to present your case. Your appeal rights are explained in an attachment to this letter. Please read them carefully. If you believe we have missed some important information about your eligibility, or if you wish to discuss this notice, please contact the WIC Clinic. If your situation has changed since you received this notice, please call to reapply. We hope you will use the other health services and please call us if you need information on nutrition.

WIC Project Name Address City, State, Zip Phone

WIC Staff Signature: In accordance with Federal law and U. S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.

DEPARTMENT OF HEALTH AND FAMILY SERVICES DPH 40085 (rev. 05/06) Page 2 of 2

STATE OF WISCONSIN

WIC PROGRAM RIGHT TO APPEAL DECISIONS

1. You may request a hearing if you disagree with the decision. 2. You may request a hearing if you believe you have been treated unfairly. 3. A request for a hearing must be made within 60 days of the date of this notice. 4. If you are now receiving WIC checks and the decision is appealed by you within 15 days of this notice, you will continue to receive WIC checks. Your checks will stop if the hearing examiner rules in favor of the WIC Clinic, or when your certification period is completed, whichever comes first. 5. If you request a hearing, you will have the following rights:

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To attend the hearing. To speak for yourself or to have a lawyer, relative, friend, or another person to speak for you at the hearing. To request a language or sign language interpreter, or other accommodations for a disability be provided during the hearing. Notify WIC staff when you request a hearing. To present oral or written evidence at the hearing to support your side. To bring witnesses or present arguments to support your side. To read all documents on file, both before and during the hearing, which concern your case that are not confidential. To be given a list of the people who will be at the hearing if you ask for it. To question any evidence. To meet and question witnesses. To withdraw the request in writing.

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In accordance with Federal law and U. S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.