OFFICE OF ADMINISTRATIVE HEARINGS STATE OF CALIFORNIA GENERAL JURISDICTION DIVISION For more information visit www.dgs.ca.gov/oah State Agency Request to Set Case Information Date Case Name Name of Agency Agency Attorney/Representative Name: Address: Respondent/Appellant/Petitioner Name: Address: From OAH Case Number Agency Case Number Respondent/Attorney/Representative Name: Address: Telephone: Fax: Email: Preferred Method of Service: Email Fax U.S. Mail Accusation Statutory Time Limit: Yes No Telephone: Fax: Email: Preferred Method of Service: Email Fax U.S. Mail Statement of Issues Telephone: Fax: Email: Preferred Method of Service: Email Fax U.S. Mail Other (Initial Pleadings must be attached) IF PLEADINGS ARE NOT ATTACHED A HEARING MAY NOT BE SET If yes, provide legal authority If yes, date by which case must be heard. (Code & Section Number) (Month/Day/Year) Days Hearing Location: Dates unavailable for at least 6 months (All Parties) Time estimate for hearing: Hours Provide at least three dates preferred (All Parties) (CCR, tit. 1 � 1018(a)(6)) Dates coordinated with all parties? Yes No If no, attach DGS-OAH Form 20 Reasonable Efforts to Confer). Failure to coordinate dates or provide an explanation will result in OAH assigning hearing dates. Additional comments and/or instructions: request for accommodation, request for security, etc. List any respondents who did not file a Notice of Defense. Electronic recording by consent (Gov. Code, � 11512, subd. (d)) (attach copy of written consent) OAH to request court reporter Agency to provide court reporter (If no selection is made a Court Reporter will be ordered and the agency will be charged.) 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 OAH processes this form. Sacramento Office 2349 Gateway Oaks Drive, Suite 200 Sacramento, CA 95833 Phone: 916-263-0550 Fax: 916-376-6349 Email: sacfilings@dgs.ca.gov DGS-OAH 13 (Cal. Code Regs., tit. 1, � 1018) (Rev. 2/16) Los Angeles Office 320 West Fourth Street, Suite 630 Los Angeles, CA 90013 Phone: 213-576-7200 Fax: 916-376-6324 Email: laxfilings@dgs.ca.gov Oakland Office 1515 Clay Street, Suite 206 Oakland, CA 94612 Phone: 510-622-2722 Fax: 916-376-6323 Email: oakfilings@dgs.ca.gov San Diego Office 1350 Front Street, Room 3005 San Diego, CA 92101 Phone: 619-525-4475 Fax: 916-376-6325 Email: sanfilings@dgs.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com