Form 4800-DA, 4800-D Addendum

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Effective Date: 10/2009


Updated: 10/2009


Form 4800-DA, 4800-D Addendum, serves as a document for staff or other program staff to record additional names of other participants to be entered in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearing system. These are the names of additional staff or individuals outside the program or agency area who are to be notified of the date and time of a hearing.


When to Prepare

The program representative prepares Form 4800-DA in conjunction with Form 4800-D, Fair Hearing Request Summary, when there are more than three other participants who require notification of the date and time of a hearing.

Transmittal and Copies

The program representative sends Form 4800-DA with Form 4800-D to the designated data entry representative (DER) for the program area. For programs with direct access to the TIERS Fair Hearings and Appeals system, the information may be entered directly. Send one copy to the program area supervisor.

Form Retention

Retain a copy of Form 4800-DA for the case record file.

Detailed Instructions

Other Participants

Continue listing other participants from Section 8 of Form 4800-D.

Enter the name of any other participants who are required or have requested to attend the fair hearing. This includes any additional program staff required to attend a hearing.

If the case manager or program representative was not listed as the agency representative, then their name must be listed here.

For each participant listed, enter the name, organization and title. Example: John Smith, case manager.

Enter the participant type for each name. The selection for participant type is:

Agency Witness

Appellant Witness


If the participant will need an interpreter, enter the language.

If the participant will need a special accommodation, enter the accommodation type needed. (Refer to the menu in Item 4A.)

Enter the participant’s mailing address. Include the county and the participant’s area code and telephone number. For agency staff, enter the mail code.

Enter the participant's email address.