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.)
* Last Name:
* First Name:
Middle Initial:
* Street Address:
Suite/Floor/Apt#:
* City:
* State:
Zip Code:
Email Address:
Phone:(include area code, no dashes)
Date of Birth (MM/DD/YYYY):
SSN:(numbers only, no dashes)
Gender (click one):	MaleFemale
Case Information
Fair Hearing #:
Case #:
Client ID Number (CIN):
Upstate County or NYC Center #:
Representative/Requestor Information
(If there is a representative or you are NOT the person listed above.)
Name:
Representative Organization:
Street Address:
Suite/Floor/Apt#:
City:
State:
Zip Code:
Phone:(include area code, no dashes)	Extension:
Email Address:
* 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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