Osah Form 1 - Georgia Office Of State Administrative Hearings printable pdf download

Osah Form 1 - Georgia Office Of State Administrative Hearings

OSAH FORM 1

This form is available online at

or by telephone request at (404) 657-2800.

OSAH USE ONLY

AGENCY

CASE TYPE

DOCKET NUMBER

COUNTY

JUDGE

DOCKET NUMBER:

PRS

PUBLIC RETIREMENT SYSTEMS

(Economic Impact of Employment Related Crime Case)

Check Applicable Retirement System Below:

(ACCG) ASSOCIATION COUNTY COMMISSIONERS OF GEORGIA, DB BOARD OF TRUSTEES OF THE

(ERS) EMPLOYEES' RETIREMENT SYSTEM OF GEORGIA, BOARD OF TRUSTEES OF THE

(TRS) TEACHERS RETIREMENT SYSTEM OF GEORGIA, BOARD OF TRUSTEES OF THE

(PSERS) PUBLIC SCHOOL EMPLOYEES RETIREMENT SYSTEM, BOARD OF TRUSTEES OF THE

(GMEBS) GEORGIA MUNICIPAL EMPLOYEES BENEFIT SYSTEM, BOARD OF TRUSTEES OF THE

(GLRS) GEORGIA LEGISLATIVE RETIREMENT SYSTEM, BOARD OF TRUSTEES OF THE

(GFPF) GEORGIA FIREFIGHTERS' PENSION FUND, BOARD OF TRUSTEES OF THE

(GCNFDPF) GEORGIA CLASS NINE FIRE DEPARTMENT PENSION FUND, BOARD OF TRUSTEES OF THE

(SCJRF) SUPERIOR COURT JUDGES RETIREMENT FUND OF GEORGIA, BOARD OF TRUSTEES

(JPCRF) JUDGES OF THE PROBATE COURTS RETIREMENT FUND OF GEORGIA, BOARD OF COMMISSIONERS OF THE

(SCCRF) SUPERIOR COURT CLERKS' RETIREMENT FUND OF GEORGIA, BOARD OF COMMISSIONERS OF THE

(SRF) SHERIFFS' RETIREMENT FUND OF GEORGIA, BOARD OF COMMISSIONERS OF THE

(POABF) PEACE OFFICERS' ANNUITY AND BENEFIT FUND, BOARD OF COMMISSIONERS OF THE

(GJRS) GEORGIA JUDICIAL RETIREMENT SYSTEM, BOARD OF TRUSTEES OF THE

(PPCG) PENSION PLAN OF COLUMBUS GEORGIA, BOARD OF TRUSTEES OF THE

(MRF) MAGISTRATES RETIREMENT FUND OF GEORGIA, BOARD OF COMMISSIONERS OF THE

CONTACT PERSON IN PUBLIC RETIREMENT SYSTEM

NAME

TEL NO

FAX NO

CURRENT ADDRESS INCLUDING ZIP CODE ON HEARING REQUEST

POSITION

AGENCY PARTY (Plaintiff)

NAME AND TITLE OF CONTACT IN OFFICE

DIRECT TEL NO

FAX NO

CURRENT ADDRESS INCLUDING ZIP CODE

ATTORNEY NAME

TEL NO

FAX NO

ADDRESS INCLUDING ZIP CODE

GEORGIA BAR NO

NON-AGENCY PARTY (Defendant)

NAME

TEL NO

FAX NO

CURRENT ADDRESS INCLUDING ZIP CODE

TEL NO

FAX NO

ATTORNEY NAME (IF APPLICABLE)

ADDRESS INCLUDING ZIP CODE

GEORGIA BAR NO

PRS (web-version) Revised 8/28/12

Osah Form 1 - Georgia Office Of State Administrative Hearings

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