Fair Hearing Request Form printable pdf download

Fair Hearing Request Form

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

Fair Hearing Request Form