REQUEST FOR AN INFORMAL HEARING: Termination

818 South Flores Street | San Antonio, Texas 78204 | 210-477-6262 | www.saha.org
REQUEST FOR AN INFORMAL HEARING: Termination
ATTENTION: Marvin Itzep
PARTICIPANT INFORMATION
Participant Name (print):
Date:
Social Security Number:
Email:
Home Telephone:
Work Telephone:
Current Address:
City:
State:
Zip Code:
I hereby request an informal hearing because I disagree with SAHA’s decision regarding the
determination to terminate my family’s assistance. I believe I have been wrongfully terminated for the
following reason(s):
 I am submitting a Request for Reasonable Accommodation, as I believe that my disability is a contributing
factor to this determination. (Please attach the Request for Reasonable Accommodation).
By signing below, I certify that the information above is true and complete. I understand that I must
submit any evidence to SAHA at least one day before my scheduled hearing date. I also understand
that I may request to review and/or make copies of documents in my SAHA file, Monday through
Thursday, from 9 a.m. to 11 a.m., up to one business day before my scheduled hearing date.
__________________________________
___________________
Participant Signature
Date
***SAHA will notify you of the outcome of this request within 30 business days of this request. ***
 Approved  Denied By:
Date:
FOR OFFICIAL
USE ONLY
Any individual with a disability or other medical need who requires an accommodation should contact the San Antonio Housing Authority
at (210) 477-6262. Si usted no comprende este documento porque está escrito en inglés, por favor llame al
(210) 477-6262 para asistencia.
Page 1 of 1
Rev. 3/25/2013
AHP-7202