Page 1

OFFICE OF THE OMBUDSMAN AND COMMUNICATIONS SAN FRANCISCO HOUSING AUTHORITY

EDW IN M. LEE, MAYOR REV. AMOS C BROW N, CHAIRMAN

Any individual with a disability or other medical need who needs accommodation with respect to this form should inform the Department.

Request for Informal Grievance Settlement Hearing I request an Informal Hearing regarding my Conventional Housing Assistance. I am requesting a Hearing because I dispute the following action by the San Francisco Housing Authority: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________ Date of the action: _____________________________________________________ The reason(s) I dispute the action of the San Francisco Housing Authority is as follows, (please be specific): _______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________ (use additional pages if necessary)

__________________________________________ Signature __________________________________________ Printed Name __________________________________________ Address __________________________________________ Telephone Number __________________________________________ Client Number __________________________________________ Date

1815 EGBERT AVENUE, 3RD FLOOR SAN FRANCISCO, CALIFORNIA 94124 TELEPHONE: (415) 715-3951 TTY: 415.467.6754 WWW .SFHA.ORG

SFHA_Public_Housing-Informal_Grievance_Settlement_Hearing_Request_2011  

__________________________________________ Client Number __________________________________________ Telephone Number E DWIN M. L EE , M AYOR...