Section 1 of 1 in this document
Applicant Informal Review & Participant Informal Hearing
Full Name of Applicant/Head of Household
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Preferred name or nickname:
I am formally requesting an informal review/hearing because:
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Are you Disabled?
Yes
No
If Yes, please choose all that apply.
Hearing Impaired
Visually Impaired
Primary language?
English
Spanish
Korean
Are you or any adult member in your household able to participate in an English language remote hearing?
Yes
No
Are you or any adult member in your household able to participate in an English language remote hearing?
Yes
No
Are you able to and voluntarily choose to use the assistance of an adult family or friend to assist in language translation?
Yes
No
Are you able to and voluntarily choose to use the assistance of an adult family or friend to assist in language translation?
Yes
No
Do you or any other adult member of your household have access to a computer, laptop, tablet, and/or smartphone with a front facing camera?
Yes
No
Are you able to and voluntarily choose to use devices of family & friends?
Yes
No
Do you/they have access to internet?
Yes
No
Are you able to and voluntarily elect to use internet access of family and friends?
Yes
No
Are you able to participate in a Video conferencing remote hearing via internet Zoom meeting?
Yes
No
HABC will work to accommodate an in-person hearing appointment
How would you like any requested documents delivered?
Email (Fastest method)
Mail
Fax
Email
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Mail
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Fax
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Assisted Housing Specialist
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Choose One
Jocelyn Arenas
Renee Camel
Denise Elder
Diana Lara
Latasha Lang
Stephanie Ledesna
Lauren Saccomondo
Alba Schwarz
Maria Scott
Alba Velasquez
Vicky Williams
Not Sure
Are you or someone assisting you in the completion of this form?
Self
Family/Friend
Social Worker or Other
HABC Employee
Upload any Supplemental Docs here
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Sign Here (Signature required of the person filling out form)
Sign Here (Signature required of the person filling out form)
First Name
Last Name
Email
Choose how to sign
Draw
Type
I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.
Full Name (Name of person assisting in completing form on behalf of client)
First Name
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Last Name
*
Email
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Phone Number
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Relation to Applicant?
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Name of Agency
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Full Name (Name of person assisting in completing form on behalf of client)
First Name
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Last Name
*
Email
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Phone Number
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Full Name(Name of person assisting in completing form on behalf of client)
First Name
*
Last Name
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Description of log of voice call
*
disregard this