(GS) Representative Authorization

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Representative Authorization

I authorize

to represent me in an administrative appeal of the denial, loss, or reduction of my financial assistance benefits. The responsible state and local agencies, and the Office of Administrative Courts, are authorized to communicate and share information with my authorized representative as necessary to process this appeal.

Appellant Signature

Today's Date

Case Number

XXX-####-####

Signature

I accept this appointment as authorized representative. My contact information is:

First Name

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

###-###-####

Email Address

Contact Preference

You have selected traditional mail as your preferred contact method. This may result in delay in receipt of any procedural or final order. If you accept these terms, please check below. If you do not, please select "Email."

I accept

(Signature) Authorized Representative:

** A public assistance applicant or recipient is entitled to be represented at an appeal hearing by an authorized representative, such as an attorney, relative, friend, or other spokesperson. See 9 CCR 2503-6, § 3.609.9.D.1.a (Colorado Works); 9 CCR 2506-8, § 3.850.15.B (OAP, AND, HCA, LEAP, and other financial assistance programs); and 10 CCR 2506-1, §§ 4.4410.131.A and 4.4410.33 (Food Assistance).

Save my progress and resume later | Resume a previously saved form

Need assistance with this form?