REQUEST FOR STATE HEARING Hearing Request Form Please complete this form and mail it to: Division of Administrative Hearings, The Chancery, 1120 Lincoln Street, Suite 1400, Denver, Colorado 80203. Name (Please Print):__________________________________________________________________ Home Address:________________________________________________________________ __ City & Zip Code__________________________________________________________________ Home Phone:__________________Household or ID Number:___________________________________ Social Security Number:________________________________________________________________ _ I request a State hearing before an Administrative Law Judge. At the State hearing, I will appeal adverse action(s) taken by: [_]State Department of Health Care Policy and Financing [_]County Department of Social Services. Which county?______________________________________ Who has been working with you at the county?_________________________________________ What is their phone number?__________________Was a conference held? Yes[_] No[_] [_]Other_________________________________________________________________ ____________ Please list the types of assistance you have been receiving_________________________________________ What type of assistance was affected?_______________________________________________________ What happened to your assistance? American LegalNet, Inc. www.USCourtForms.com [_]Terminated[_]Amount Changed [_]Application was Denied[_]Recovery of overpayment [_]Other Please attach a copy of the notice which you received from the Agency. If my home address or phone number changes, I will immediately notify the Division of Administrative Hearings at the above address or telephone number (303) 894-2500. I understand that my appeal can be dismissed if the Division is unaware of my current address or if my appeal is not submitted in a timely manner. Date :____________________ Signature: ___________________________ Last Modified December 31, 2003 American LegalNet, Inc. www.USCourtForms.com