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.

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?

Please indicate the county or agency that took the adverse action below.  Also, please attach a copy of any notice which were sent by the county or agency notifying the benefit recipient of this action.

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.