Georgia Department of Human Services
EMPLOYMENT INTERVENTION SERVICES
________________________ County Department of Family and Children Services
Case Name ________________________________ Date mailed/given to AU _____________________
Client Name ________________________________ Case Manager’s Name/Load ___________________
Client ID Number ____________________________ Case Manager’s Phone Number _________________
PROCEDURES TO REQUEST A HEARING ARE ON THE BACK OF THIS FORM
FOR FREE LEGAL SERVICES CALL: _____________________________
Please check appropriate box(es):
□ Your TANF application dated ___________ is denied effective _______________ because:
□ You chose not to receive TANF at this time because, due to your recent employment, you
are not eligible to receive full benefits.
□ You chose not to receive TANF at this time because you are returning to your job within 4
□ You are approved to receive a one-time only Employment Intervention services (EIS) cash
payment of $__________.
□ You are ineligible to receive TANF for twelve months effective: ____________________.
Client’s statement of understanding:
EIS payment rules have been explained to me. I agree to receive $_________ cash assistance instead
of TANF because ____________________________________________________________________.
I understand that I will not be eligible to receive TANF for 12 months effective: ________________.
Clients signature Date
Case manager's name/caseload Date
Form 205 (04/2006)
If you want a hearing, fill out this form and return the top Today’s Date
portion to your county Department of Family and Children
Signature of Person Requesting Hearing Telephone Number Where You Can Be Reached
Use this space to tell us why you want a hearing: __________________________________________
CHECK () ONE
□ I DO NOT WANT to continue receiving the cash assistance I now receive while waiting for the
□ I WANT to continue receiving the cash assistance I now receive while waiting for the hearing
decision. I understand that I WILL BE REQUIRED TO REPAY the Department of Human
Services any overpayment in TANF cash assistance to which I was not entitled as determined by
the hearing official.
If your eligibility changes, you will be advised in writing. If, for any reason, you think proper consideration has not been given to
your situation, you have the right to request a hearing with the Office of State Administrative Hearings.
Procedures for requesting a hearing are below.
If you request a hearing within ten days from the date on the top front of this form, your TANF cash assistance may be
continued or your case returned to the same status it was in prior to this action, unless the hearing official decides the sole
reason is one of state or federal law or policy.
You may request a hearing either orally or in writing by notifying the county Department of Family and Children Services. You
have thirty days from the date on this form to request a hearing. If you request a hearing for TANF orally, you have fifteen
days from the date of your oral request to submit your request in writing. The hearing is held for TANF by a representative of
the Office of State Administrative Hearings. Any member of the staff will be glad to furnish the necessary forms and help you
request a hearing, and assist you in every way possible to prepare for the hearing.
You may be represented at such a hearing by an authorized representative, such as legal counsel, a relative, friend or other
spokesperson, or you may represent yourself. Free legal services may be available to you in your community. If you are
interested in legal services, call the number for free legal services listed on the front of this form.
Form 205 (04/2006)