REQUEST TO WITHDRAW 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.
 
This form must be completed by the appellant or AUTHORIZED representative only.
 
  Indicates Required Information. Correct and complete information will permit us to promptly process your request.
 
 
 
 
      
 
 
Appellant Information
 
 
 
 
 
 
  (please note any changes in address)
 
 
 
 
 
 
 
 
Representative Information
 
 
 
 
 
 
 
 
 
 
 
What is the reason you wish to withdraw your Fair Hearing request?
   (Examples: The issue was resolved, you no longer wish to pursue the issue, etc.)

You have 500 characters remaining for your description...
 
 
If you are NOT the appellant or authorized representative, please indicate your name and the reason (noted above) for assisting in the completion this form: