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Effective Date: 
2/2001

Documents

Instructions

Updated: 7/2009

Purpose

Form H4809 is a data entry form. Staff in the Appeals Office enter the data contained on the form into the MAPPER System.

Procedure

When to Prepare

The hearings officer prepares Form H4809 after making the final decision, including the decision to accept a withdrawal or to dismiss the appeal.

Prepare a separate Form H4809 for each appellant and/or each program appealed. Prepare a separate form for each appellant in the same household unless it is a case with a couple. Prepare a single form for a case with a couple.

Number of Copies

Prepare an original.

Transmittal

Hearings Officer Action

The hearings officer completes Form H4809 and submits it to the person who will enter the information into the Fair Hearings and Fraud System.

Form Retention

  • Fair Hearing Appeals and Administrative Disqualification Hearings — four years
  • Food Stamp Fair Hearing Appeals and Administrative Disqualification Hearings — three years

Detailed Instructions

1. Identification

Appellant — Enter the name of each appellant as shown in the case record.

Program — Enter the name of the program being appealed. The name must correspond to the programs listed in Item 1 of Form H4800.

Case/Client No. — Enter the case number from Form H4800 for the appellant. For services appeals, enter the client number. If neither case or client number is available, enter the appellant's Social Security number.

County — Enter the name of the county in which the appellant lives.

Region — Enter the number of the region in which the case is located.

2. People Present for Fair Hearing

Enter the names of all people attending the fair hearing (including the hearings officer and anyone on the telephone) and the capacity in which each serves.

3. Principal Issue

Using Appendix C, Pages C-1, C-2 and C-3 of the Appeals and Fraud Tracking System User Guide, enter the one code that most appropriately describes the principal issue in the fair hearing.

4. Representation of Appellant during Hearing

Complete this item only if the appellant is represented at the fair hearing. Enter the code that best describes the representative:

-Code Representative
-A. Legal Aid, American Civil Liberties Union or other free legal counsel
-B. Law student
-C. Private attorney
-D. Other

5. Type of Hearing

Place an X in the appropriate box indicating whether the hearing was face-to-face or a telephone hearing. If the hearing is dismissed or the request for a hearing is withdrawn, place an X in Withdrawn/Dismissed.

6. Nature of Request

Check the appropriate box to show whether the appellant is requesting the fair hearing to challenge fact or judgment or to protest HHSC policy.

7. Use of Interpreter

If an interpreter was used, place an X in Yes. Also, place an X in either ASL, Spanish or Other. (Interpreter is defined in Item 1140, Definitions, Fair and Fraud Hearings Handbook.)

If an interpreter was not used, place an X in No.

8. Record of Action Taken

Date of Request — Enter the date the appellant first requested a fair hearing. This may be the date HHSC learned of the request or the date correspondence or a telephone call was received in which the appellant expressed dissatisfaction.

Date and Place of Fair Hearing — Enter the date and address of the fair hearing.

Nature of Decision — Check the appropriate type of decision. Check "Withdrawn — in favor of appellant" if the appellant withdraws the appeal as a result of the worker's subsequent favorable action. Check "Withdrawn - no change in status" for other withdrawn cases.

Date of Action from which Appeal is made — Enter the date the worker or other agency person made the decision that is being appealed. Usually, this is the date on the program decision/denial/reduction form that reports the adverse action.

Effective date of Hearings Officer's Decision — Enter the date the decision takes effect.

Date Decision Mailed to the Appellant — Enter the date the decision was mailed. This should be the same date as on the hearings officer's cover letter to the appellant.

9. Delay of Hearing Decision

Was hearing decision delayed ? — Check Yes or No to indicate whether the appellant requested a continuance or a rescheduling of the hearing, or if allowed circumstances beyond HHSC's control delayed the hearing decision.

If yes, enter the delay code that applies:

  1. Continuance not to exceed 30 days from last scheduled hearing date.
  2. Record left open for a specific period of time after a hearing. Appellant must sign Form H4804, Request and Authorization for Fair Hearing Record to Remain Open.
  3. Circumstance beyond HHSC's control; for example, fire, floods, acts of nature. If C is used, the reason must be explained.

Name of Hearings Officer — Enter the name of the hearings officer issuing the decision.

Decision Date — Enter the date of the decision.