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Georgia Department of Human Resources
NOTIFICATION FORM FOR CHANGE IN CASE PLAN/SERVICES - PLACEMENT
     
Agency Name
     
Date
     
Case ID
A social service(s), which is (are) identified below, will be:
1. Denied, effective       Service(s)      
2. Reduced, effective       Service(s)      
3. Terminated, effective       Service(s)      
Visitation or transportation to visitation of child(ren) will be:
1. Denied, effective      
2. Reduced, effective      
3. Terminated, effective      
A determination has been made that the parent must participate in a service as
outlined in the Case Plan.
The County Department was unable or failed to provide/arrange certain services and
supports as specified in the Case Plan. Explain:     
     
     
A change in the Case Plan/decision. Explain:      
     
     
If for any reason you disagree with this decision, you may request a hearing. You may
request a hearing orally or in writing by contacting this agency within 30 days of the date
given at the top of this form. This agency will be glad to furnish the necessary form(s)
and help you in filing your appeal. An oral request for a hearing must be followed in
writing within 15 days of the date given at the top of this form.
The hearing will be held by an Administrative Law Judge of the Office of State
Administrative Hearings (OSAH). You may be represented at the hearing by legal
counsel, a friend, or other spokesperson.
Signature of Agency Representative
FC 141 Notification Form for Change in Case Plan/Services – Placement (Rev. 11-03) Page 1 of 1

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Fc 141 notification for change in case plan services

  • 1. Georgia Department of Human Resources NOTIFICATION FORM FOR CHANGE IN CASE PLAN/SERVICES - PLACEMENT       Agency Name       Date       Case ID A social service(s), which is (are) identified below, will be: 1. Denied, effective       Service(s)       2. Reduced, effective       Service(s)       3. Terminated, effective       Service(s)       Visitation or transportation to visitation of child(ren) will be: 1. Denied, effective       2. Reduced, effective       3. Terminated, effective       A determination has been made that the parent must participate in a service as outlined in the Case Plan. The County Department was unable or failed to provide/arrange certain services and supports as specified in the Case Plan. Explain:                  A change in the Case Plan/decision. Explain:                   If for any reason you disagree with this decision, you may request a hearing. You may request a hearing orally or in writing by contacting this agency within 30 days of the date given at the top of this form. This agency will be glad to furnish the necessary form(s) and help you in filing your appeal. An oral request for a hearing must be followed in writing within 15 days of the date given at the top of this form. The hearing will be held by an Administrative Law Judge of the Office of State Administrative Hearings (OSAH). You may be represented at the hearing by legal counsel, a friend, or other spokesperson. Signature of Agency Representative FC 141 Notification Form for Change in Case Plan/Services – Placement (Rev. 11-03) Page 1 of 1