Date:
Medina County Veterans' Service Commission
210 Northland Drive - Medina, Ohio 44256
Phone: (330) 722-9368 - FAX: (330) 722-9378
VS Form AS-04
To:
Medina County
Veterans' Service Commission
210 Northland Drive
Medina, Ohio 44256
330-722-9368
Client information:
Name:
STATEMENT OF APPEAL RIGHTS
You have been tentatively denied assistance for the reasons listed below. You have the right to appeal this
decision. To do so, all that is required is for you or your legal representative to personally appear before the
Veterans Service Commission at the next regular scheduled board meeting, unless otherwise directed in writing.
The next regular board meeting will be held on _____________________ at __________ PM. If you do not
appear or otherwise submit a written notice prior to that time, you will be deemed to have accepted the tentative
denial and it will be final.
Print Name Signature
MCVSO Official:
THIS SECTION TO BE COMPLETED BY MEDINA COUNTY VETERANS' SERVICE COMMISSION
Client was denied for reason listed below:
SSN:
Record Notes Below and Copy into Folder:
Approved Denied Show No-Show Other
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