REQUEST FOR COMPLIANCE
Office of Administrative Hearings
P.O. BOX 1930
Albany, NY 12201-1930
Fax:(518) 473-6735
 
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.
 
  Indicates Required Information. Correct and complete information will permit us to promptly process your request.
 
Personal Information
(If fair hearing is for someone other than the case name, describe who it is for in the comments box below.)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Case Information
 
 
 
 
 
Representative/Requestor Information
(If there is a representative or you are NOT the person listed above.)
 
 
 
 
 
 
 
 
 
 
  I do not feel the local social services agency has complied with my decision because:
(Please be specific and brief, including dollar amounts and dates when possible.)
 
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  Enter the name of person filling out this form