Case Name:
State Hearing No:
County:
County Case No:
Filing Date:
Hearing Date:
Hearing Time:
I,
, the undersigned do hereby:
Withdraw my request for a state hearing before the State Department of Social Services. I understand that by
withdrawing my request, I lose my right to a hearing on that request. I also understand that by withdrawing my request
for hearing, aid which has been paid because of the request will stop without further notice. I may, however, file a new
hearing request raising the identical issue provided that the new request is timely per Manual of Policies and
Procedures Section 22-009.
Conditionally withdraw my request for a state hearing before the State Department of Social Services. I understand
that by conditionally withdrawing my request for hearing, aid which has been paid because of the hearing request will
stop without further notice. I understand that the county will issue a redetermination notice within 30 days and that I
must request a hearing within 90 DAYS of the county's notice if I am not satisfied with the county's reconsideration of
my case. Upon such renewal, I shall have the same rights I would have had if I had not signed this conditional
withdrawal.
NOTE: A conditional withdrawal must provide that the actions of both parties will be completed within 30 days.
Signed
(County Representative)
(Date)
(County Address)
(City) (Zip Code)
(Telephone Number)
Signed
(Claimant)
(Date)
(Address)
(City) (Zip Code)
The reasons for or conditions of this withdrawal are:
NOTE: A Conditional Withdrawal must also be signed by a County Representative or it is in
(Telephone Number)
valid.
DPA 315 (7/99)
