DCF-800A



DCF-800A State of Connecticut

7/06 (Revised) Department of Children and Families

CLIENT'S AGREEMENT TO SUSPEND, REDUCE OR TERMINATE

DEPARTMENT OF CHILDREN AND FAMILIES BENEFITS

Date:_____/_____/_____

I __________________________________,

(address)

agree with the Department's decision to

[pic]1 SUSPEND [pic]2 REDUCE [pic]3 DISCONTINUE [pic]4 DENY

my Department of Children and Families benefits effective _____/_____/_____ for the reason stated on DCF-800 which is as follows:

I understand that by signing this agreement I do not forfeit my right to a fair hearing on this issue at a later time.

_____________________________________________ ______/______/______

Signature of Worker Date

_____________________________________________ ______/______/______

Signature of Client/Caretaker Date

Mail this form to:

Area Office Address

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