Request for State Level Hearing

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Section A - Contact Information
Please enter Appellant or benefit recipient contact information here.









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Section B - Representation

Check this box if you will have someone else represent you and complete the information below. Your representation will need to send the OAC a statement in writing that they agree to represent you. If you will not be represented by another person, please proceed to Section C below.












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Section C - Appeal Information

I request a State Level Hearing before an Administrative Law Judge.  I am appealing the following adverse action: (Check all that apply)


What happened to your assistance?

Section D - Agency Information

Please indicate the county or agency that notified you of this adverse action below.  Also, please attach a copy of any notice which you received from the county or agency notifying you of this action.

County

Attach additional documents
Use this section to upload copies of termination notices, Power of Attorney documents or any other documents you want to include with your request.


Signature

If my home address or phone number changes, I will immediately notify the Office of Administrative Courts at the above address or by telephone at (303) 866-5626.



If this request is being submitted for an IPV hearing, the County Representative submitting this form should sign above.

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