Appeal Form

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Appeal Form

Please complete this form entirely if you would like to appeal your application decision. Additionally, email any supporting documents to saftulsaapplication@gmail.com. Supporting documents could include proof of income for all working adults in the household or copies of bills.

Email *

Name *

Phone Number (Needed for contact purposes)

Email address (Needed for contact purposes)

What reason were you given for why your application was denied? *

Did you submit a copy of the following documents to your Case Manager? *

Copy of ID

Proof of ALL income sources for ALL adult members of the household

Copy of monthly bills

Reason for appeal? *

Submit

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