Adjournment Request

REQUEST TO ADJOURN A FAIR HEARING
Office of Administrative Hearings P.O. BOX 1930 Albany, NY 12201-1930 (877) 209-1134

Note: For security purposes, you have 15 minutes to complete this form, otherwise your request will not be received and you will need to start over.

WRITTEN REQUESTS FOR ADJOURNMENTS SUBMITTED LESS THAN SEVEN DAYS PRIOR TO THE HEARING MAY NOT ALLOW SUFFICIENT TIME FOR PROPER PROCESSING AND WRITTEN RESPONSE SHOULD IT BE NECESSARY.

* Indicates Required Information. Correct and complete information will permit us to promptly process your request.

* Fair Hearing Number:
Case #:
* Hearing Date (mm/dd/yyyy):
Hearing Time (00:00)	AMPM
Upstate County or NYC Agency

Appellant Information
* Last Name:
* First Name:
Middle Initial:
Check box if new address
* Street Address:
please note any changes in address
Suite/Floor/Apt#:
* City:
* State:
Zip Code:
Phone: (include area code, no dashes)
Alternate Phone Number: (where you can be reached) (include area code, no dashes)

Representative Information
(If there is a representative or you are NOT the person listed above)
Name:
Representative Organization: (if applicable)
Street Address:
Suite/Floor/Apt#:
City:
State:
Zip Code:
Phone: (include area code, no dashes)	Extension:(limit 5 numbers)

Please enter an email address for Yourself or Representative: (if no email address is available enter the name of the person filling out this form)
Email:

RESTRICTIONS FOR FUTURE RESCHEDULING
Mark the days or times you or your representative cannot participate in a hearing and explain in the comment box below.
	M T W TH F
Morning
Afternoon

What is the reason you cannot attend at these times?
You have 500 characters remaining for your description...

* What was the reason you cannot or did not appear at the hearing?
You have 500 characters remaining for your description...

We will notify you if your request for Adjournment/Rescheduling is denied.

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