Review of Hearing Office Decision Letter

Review of Administrative Law Judge’s Decision Letter

This letter is used when you received a Fair Hearing decision that you disagree with and want to appeal it further.

Your Name(Required)

First Last

Your Email(Required)

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Recipient's Name(Required)

Recipient's Email(Required)

VR Counselor(Required)

Recipient's Address

Street Address Address Line 2 City State ZIP Code

Appeal Number(Required)

Decision being Appealed(Required)

(e.g. close my case, discontinue, reduce or suspend a vocational rehabilitation service, deny eligibility for services)

Why do you believe this decision was wrong?(Required)

Date of Decision(Required)

Hidden

Please provide your answer to my request in writing by