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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