OAH 21E STATE OF CALIFORNIA OFFICE OF ADMINISTRATIVE HEARINGS REGIONAL CENTER REQUEST TO SET LANTERMAN FAIR HEARING / MEDIATION (Cal. Code Regs., tit. 1, § 1018) DATE: CLAIMANT NAME NAME OF REGIONAL CENTER REGIONAL CENTER ATTORNEY/REPRESENTATIVE Name, Address, Telephone, E-mail & Fax CLAIMANT Name, Address, Telephone, E-mail & Fax FROM: OAH CASE NO. AID PAID PENDING CLAIMANT AUTHORIZED REPRESENTATIVE /ATTORNEY Name, Address, Telephone, E-mail & Fax. Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail HEARING ONLY PLEASE LIST EACH PARTY SEPARATELY ­ USE ADDITIONAL SHEETS IF NECESSARY Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail HEARING AND MEDIATION MEDIATION: ACCEPTED DENIED DATE FAIR HEARING REQUEST RECEIVED BY REGIONAL CENTER TIME ESTIMATE FOR HEARING HOURS DAYS DATES PREFERRED (ALL PARTIES) TIME ESTIMATE FOR MEDIATION HOURS DAYS DATES UNAVAILABLE FOR NEXT 90 DAYS (ALL PARTIES) INTERPRETER NEEDED? LANGUAGE: HEARING LOCATION DATES COORDINATED WITH ALL PARTIES? YES NO ADDITIONAL COMMENTS AND/OR INSTRUCTIONS WHICH WOULD AFFECT CALENDARING, REQUEST FOR ACCOMMODATION, ETC. COMPLETED BY: DATE COMPLETED: DATE TO OAH: NOTICE: This is not a reservation of dates. Completion of this form does not guarantee that you will receive the hearing dates requested. Dates are subject to availability at the time a Request to Set or other calendar request is processed by OAH. For more information visit www.dgs.ca.gov/oah American LegalNet, Inc. www.FormsWorkFlow.com