Withdraw Request

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.

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

Appellant Information
* Last Name:
* First Name:
Middle Initial:
Last four digits of Social Security Number:
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)
Email Address:

Representative Information
Name:
Relationship to Appellant:
Representative Organization: (if applicable)
Street Address:
Suite/Floor/Apt#:
City:
State:
Zip Code:
Phone: (include area code, no dashes)	Extension:(limit 5 numbers)
Email:

* 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:
Name:
Relationship to Appellant:
Phone: (include area code, no dashes)

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