Form Occ 1281 Request For Hearing
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1MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
REQUEST FOR HEARING
Upon completion, file this Appeal with:
Office of Child Care
ATTN: Legal Enforcement Unit
th
200 W. Baltimore Street, 10
Floor
Baltimore, Maryland 21201
NOTE: If this is an appeal of an emergency action, you may hand deliver it to your OCC Regional Office.
I, _________________________________________, of _________________________________________________
Appellant’s Name
Street or RFD
__________________________ ____________________________ ____________ __________ ______________
City/Town
County
State
Zip
Telephone Number
hereby request a hearing.
I am appealing the following:
My Appeal involves:
(Check appropriate space)
(Check appropriate space)
_____ Denial of initial application
_____ Family Child Care Home
_____ Denial of application for continuing
_____ Child Care Center
registration/license/letter of compliance
_____ Letter of Compliance facility
_____ Emergency suspension of
registration/license/letter of compliance
_____ Non-emergency suspension of
I will _____
will not _____
registration/license/letter of compliance
be represented by an attorney.
_____ Revocation of
registration/license/letter of compliance
_____ Reduction in capacity
Attorney’s Name ___________________________________
_____ Limitation on ages or numbers
Address __________________________________________
of children who may be admitted
Telephone No. ____________________________________
to home/center
_____ Other (Specify) ____________________________________________________________________________
I AM APPEALING because: (Please be as clear and specific as you can in stating why you want a hearing)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________
_________________________________________________
Date
Signature
NOTE: If you need help in filling out this form, please contact your local Office of Child Care Regional Office.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
TO BE COMPLETED BY THE OFFICE OF CHILD CARE
TYPE OF ACTION:
NON-EMERGENCY _______
EMERGENCY _______
LOCATION OF HEARING: _______________________________________________________
DATE OF APPEAL NOTICE: _____________________________________________________
EFFECTIVE DATE OF ACTION: __________________________________________________
DATE HEARING REQUEST RECEIVED: ___________________________________________
NAME OF PROVIDER/CENTER: _________________________________________________
OCC 1281 (Revised 8/06) - All previous editions are obsolete
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