This government document is issued by Department of Human Services for use in District of Columbia
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https://www.google.com/url?client=internal-element-cse&cx=2d618894035d0d742&q=https://dhs.dc.gov/sites/default/files/dc/sites/dhs/release_content/attachments/FAIR%2520HEARING%2520FORM%2520-%2520English.pdf&sa=U&ved=2ahUKEwiTmPG-6Pj8AhU-QEEAHUCSAfs4HhAWegQICBAB&usg=AOvVaw1nTDE7PcAjzzuklO5IKyBe