Alaska Department of Revenue Please Reply To: CSSD, MS 550 W. 7th Ave., Suite 310 Anchorage, AK 99501-6699 www. childsupport.alaska.gov Child Support Services Division Hearing Withdrawal and Consent CSSD Case No.: I, ______________________________, the Appellant in this matter, hereby withdraw my request for an Administrative Review Hearing under AS 25.27.160 or a Formal Hearing under AS 25.27.170 and: Accept the order dated ____________ as written. Consent to an ongoing child support obligation in the amount of $_______________ per month, effective _______________; plus arrears totaling $_______________ for the period beginning _______________ through _______________. Consent to a modified child support obligation in the amount of $_______________ per month, effective _______________. I understand that this settles all matters on appeal and no hearing will be held. Appellant Signature Date I, ______________________________, the Respondent in this matter, consent to the terms listed above. I understand that this settles all matters on appeal and no hearing will be held. Respondent Signature Date Approved by: CSSD Representative Signature Date CSSD 04-1916 (11/13/2012) MAT-SU: (907) 357-3550 TOLL FREE (In-state, outside Anchorage): (800) 478-3300 SOUTHEAST: (907) 465-5887 ANCHORAGE: (907) 269-6900 FAX: (907) 787-3220 FAIRBANKS: (907) 451-2830 TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894 American LegalNet, Inc. www.FormsWorkFlow.com