Free 05374.FH11 - Indiana

NOTICE REGARDING DENIAL OR PROPOSED ACTION TO DISCONTINUE ADOPTION ASSISTANCE
State Form 5374 (R4 / 3-06) / CW 0011 Names of adoptive applicants Child case name

Date (month, day, year) County Name of family case manager ICWIS adoption number

Family case number

This is to advise you that your adoption assistance application is being denied or payment is being discontinued.

Application denied Payment discontinued

Effective date (month, day, year)

This action is being taken for the following reason(s) in accord with rule _______________________________.

If you do not agree with the denial / discontinuance, you have the right to appeal this action and request a fair hearing pursuant to 470 IAC 1-4. The deadline for filing an appeal is 30 days from the date you receive this notice of action to be taken or the date that the action is to occur, whichever is later. A written request must be sent to: Indiana Department of Child Services c/o FSSA Hearings and Appeals; 402 W. Washington St., Rm. E034, MS04; Indianapolis, IN 46204. If you are unable to write this letter for yourself, contact your family case manager who will assist you in requesting this appeal. You will be notified in writing by the FSSA Hearings and Appeals on behalf of the Department of Child Services (DCS) of the date, time and place for the hearing. Prior to or at the hearing, you will have the right to examine case materials pertaining to your Adoption Assistance case at the local DCS office. You may represent yourself at the hearing or authorize a representative, such as an attorney, a relative, a friend or other spokesperson to do so. At the hearing, you will have full opportunity to bring witnesses, establish all pertinent facts, advance any arguments and questions or refute any testimony or evidence presented by the Department of Child Services.
Signature of Director Address of local DCS office Local DCS office