EXHIBIT 4.8.0 (A)
FAIR HEARING REQUEST FORM
I hereby request a hearing regarding the decision made on my application for
assistance through the Energy Assistance Program.
Please state the reason(s) why you are requesting a hearing (please be as specific as
possible -- use additional sheets of paper if necessary):
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
I was notified of the agency's decision by ______________________________
(Agency Representative)
of the __________________________________________________________
(Agency/Organization Name)
in writing on _______________________, 20__________
My name is _____________________________________________________
My phone/message number is ______________________________________
My email is _____________________________________________________
My address is ___________________________________________________
___________________________________________________
I will be represented by ____________________________________________
(If Applicable)
Signature: ______________________________
Date: ________________
Mail to:
Department of Commerce
Attn; LIHEAP EAP
1011 Plum St SE
Post Office Box 42525
Olympia, Washington 98504-2525