MFIP Alternative Employment Plan Notice



Family Violence Waiver Notice

This information is available in other forms to people with disabilities by calling your county worker or contacting them through the Minnesota Relay Service at 1-800-627-3529 (TTY) or

1-877-627-3848 (speech-to-speech relay service).

|To: |Name |wpu |Date: |11/7/2013 |

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|From: |Worker |      | | |

| |County Agency |      | | |

| |Street Address |      | | |

| |City |      | | |

| |State |      | | |

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|Purpose: |This notice tells you about the decisions the county has made on your request for the Family Violence Waiver. It also tells you when |

| |your plan needs to be revised. |

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|Family Violence Waiver |

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| | |Review |

| |Your Family Violence Waiver needs review. You need to report to your job counselor |

| |before       . If you do not report, your MFIP grant will be sanctioned and you will no longer be exempt from the 60-month |

| |limit. |

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| | |Approved |

| | |Your Family Violence Waiver is approved. You are exempt from the 60-month time |

| | |limit for cash assistance from       until      . |

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| | |Denied |

| | |Your Family Violence Waiver was denied for the following reasons: |

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|Appeal Rights | | | |

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|If you do not agree with this decision you can file an appeal. Your appeal rights are on the next page. |

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|Copies to: Client, Financial Worker, Case File |

Appeal Rights. An “appeal” is a legal process where a state referee reviews a decision made by the county agency. You may appeal a decision if:

• You feel the agency did not act on your request for assistance; or

• You are unhappy with the action taken.

For Cash and Medical Assistance, you may appeal within 30 days from the date you received this notice by writing to the county agency, or directly to the State Appeals Office. If you show good cause for not appealing your Cash and Medical Assistance within 30 days, the agency can accept your appeal for up to 90 days from the date you received this notice. “Good Cause” is when you have a good reason for not appealing on time. The human services office will decide if your reason is a good cause reason.

For Food Support, you may appeal within 90 days by writing or calling the county or the State Appeals Office.

State Appeals Office

Department of Human Services

444 Lafayette Road

St. Paul, MN 55155-3813

If you want to keep getting your benefits until the hearing, you must appeal the notice before the date of the proposed action, or within 10 days from the date you received the agency notice, whichever is later. If you can file your appeal on time, you will get your benefits until an appeals referee decides your appeal. You can ask the county to end your benefits until the decision. If you lose your appeal, you will have to pay back the benfits you got while your appeal was pending. Ask your county worker to explain how the timing of your appeal could affect your present or future assistance.

You have the right to reapply at any time if your benefits stop.

Access to free legal services. You may be able to get legal advice or help with an appeal from your local legal aid office. To contact your local legal aid office call:

Hennepin 612-334-5970

Ramsey 651-222-4731

All other Minnesota Counties 1-888-354-5522

You’re right to complain. If you feel we treated you differently in the handling of a public assistance application or payment because of race, color, national origin, political beliefs, religion, sex, sexual orientation, age or disability (including access to buildings or properties) you may file a complaint with one or more of these agencies:

State Agencies

Minnesota Department of Human Services Minnesota Department of Human Rights

Office of Equal Opportunity Army Corps of Engineers Centre

Affirmative Action and Civil Rights 190 East 5th Street, Suite 700

444 Lafayette Road St. Paul, Minnesota 55101

St. Paul, Minnesota 55155-3812

Federal Agencies

U.S. Department of Health and Human Services Administrator

Office of Civil Rights – Region V – Chicago U.S. Department of Agriculture

233 North Michigan Avenue, Suite 240 Food and Nutrition Service

Chicago, Illinois 60601-5519 3101 Park Center Drive

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