Case name: / File:
Date of notice: / Benefit effective date:
Notice of Decision and Action Taken
OAR Chapter 461, Division 135:Rules 1200, 1230, 1235
Your application for the Temporary Assistance for Domestic Violence Survivors (TA-DVS)Program has been approved. You are eligible for help to keep you safe.
This help starts / .Your help ends / .
Your plan: Your worker will work with you on a plan to help keep you safe from domesticviolence. This plan is called a “Domestic Violence Assistance Agreement.”
Talk to your worker about steps you think will help you be safe. As part of your plan, your worker may offer you other options you haven’t thought about. Your worker may refer youto other places that help survivors of domestic violence. Your plan will include things that the Department of Human Services (DHS) has agreed to pay. Before a payment is made it must be part of your plan or pre-approved by your worker.
If you need a payment that is not in your plan, talk with your worker.
Payments:Usually, DHS will pay for things needed to keep you safe, up to $1,200. How much we pay
depends on:
What you need to keep safe;
How much of your own money you have while you are getting help from DHS;
If the things you need are available at a lower cost;
If help is available from another source than DHS.
DHS usually does not make payments to you. DHS directly pays landlords or businesses that give you services. If we do pay you, you must use the payment for the items that were listed on your agreement or you may have to pay the money back.
If you are still unsafe after program benefits end, contact DHS. You can apply again to see if you qualify for additional benefits.
Questions: Talk with your worker if you have questions about the program. Your worker’s name is:
Name: / Phone:
Worker signature / DHS local office
(Note to worker: Do not mail this notice unless you know it is going to a safe address.)
TA-DVS – Emergency Assistance Hearing Rights
If you disagree with the decision on the first page of this form, you may discuss it with a person in charge before leaving the branch office.If you cannot settle it this way, you may request a hearing. The hearing will occur within
five (5) working days. At the hearing, you can explain why you disagree with the decision.
Hearings take place at the branch office or the Hearing Officer can hold the hearing bytelephone.You will get a decision in writing within three (3) working days after the hearing.
You may have witnesses and a lawyer during the hearing. You can have someone from a non-profit legal service represent you. DHS cannot pay for yourwitnesses or lawyer. You may call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at 1-800-520-5292 for advice and possible representation. You also may be able to get free or reduced-cost legal services through your local Bar Association.
To request a hearing, use an Administrative Hearing Request form (MSC 0443). Someone at the branch office can help you fill it out, if needed.
You must ask for a hearing within 45 days from the date on this decision notice to challenge your ending date. If you do not ask for a hearing on time, this notice and decision will be your final order by default for the ending date. The case file is the record. No separate order by default will be issued. You may appeal the final order by default under ORS 183.482 if you file a petition in the Oregon Court of Appeals. The appeal must be filed within 60 days of the date this notice becomes a final order by default.
The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs, disability or sexual orientation. You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons. To file a complaint with the state, you can call the Governor’s Advocacy Office at
1-800-442-5238 (TTY 711) or write to their office at:
Governor’s Advocacy Office
500 Summer Street NE, E17
Salem, OR 97301
Fax: 503-378-6532
Email: “Equal opportunity is the law!”
Page 1 of 2DHS 0456DV (01/18), can use prior version