State of California-Department of Rehabilitation Office of Administrative Hearings NOTIFICATION OF RESOLUTION Name of Person for Whom Hearing was Requested (Appellant) Address: Name of Authorized Representative: Address: OAH Case Number: Telephone Number: Telephone Number: The above referenced matter has been satisfactorily resolved through the following process: (Please check the appropriate box): Informal meeting with the Department Counselor Mediation Other (Please explain below): Signature of Claimant Or Authorized Representative Signature of Representative For Department of Rehabilitation American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS 1. You, or your authorized representative, may decide at any time during them mediation or fair hearing process that you no longer wish to have a mediation and/or fair hearing. 2. If the issue, or issues, indentified in your request for a fair hearing are satisfactorily resolved, through an informal meeting or by other means, complete and submit this form to the Office of Administrative Hearings to cancel the mediation and/or fair hearing. If the issue or issues are resolved through mediation, complete and submit this form to the mediator. 3. The decision of the Department of Rehabilitation, or the final resolution agreed to during the mediation, as appropriate, will go into effect days after receipt by the Department of Rehabilitation, or mediator of this Notification of Resolution. Distribution: Office of Administrative Hearings Department of Rehabilitation Appellant 2 American LegalNet, Inc. www.FormsWorkFlow.com