As an individual who has had a criminal record exemption denied or rescinded, you have a right to
request a copy of your state and/or federal Criminal Offender Record Information (CORI) search
response. To request a copy of your CORI, you must send a written request to the address below
within fifteen (15) days of the date of this notice. You must sign and date the request and specify an
address where the CORI is to be sent.
If you disagree with this action, you may appeal by submitting a written request and a copy of this
notice to the address below. If you wish to use this form to appeal, you may do so by checking
the box and filling out the information below, then sending all pages of this notice to the address
listed below.
[COUNTY ADDRESS:
CITY, STATE, ZIP:
ATTN: County Contact, Title]
[Appeal due dates effective 1/1/18: Exemption denial = 90 days. Exemption of rescission = 25 days.]
The due date for this appeal is
from the date of this notice.
If this decision is not appealed on or before the due date, the action will be final. The appeal
must be post marked or delivered on or before the due date.
If you appeal, you
continue to reside in the Resource Family’s home until completion
of the administrative review of your appeal. You will be contacted and provided additional
information about the appeal process at a later date. If you appeal it is required that you notify the
county, in writing, of any change in your address. Please call the Resource Family worker
at
if you have any questions regarding this notice.
______________________________________
[Sign above line, then type name & title here]
I wish to appeal. (Submit this request with a copy of this notice)
______________________________________
__________________________________
Print Name
Signature
______________________________________
__________________________________
Address
Phone Number
Reasons for appeal (optional): _______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
[For County use only. Do not write in this box.]
County: ______________________________ County RF ID#: ________________
Exemptible
Non-exemptible
Both
Forum: SHD
OAH
RFA 09B (1/18)
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