Fillable Form Rfh-Awg Dcsi-010 - Request For Hearing printable pdf download

REQUEST FOR HEARING

If you object to garnishment of your wages for the debt described in the notice, you can use this form to

request a hearing. Your request must be in writing and mailed or delivered to the address below.

Your Name: ___________________________________________________________ SSN: __________________

Address:

__________________________________________________________________________________

Telephone: _____________________

Employer: ___________________________________________________________________________________

Address:

___________________________________________________________________________

Telephone: _________________

Beginning Date Of Current Employment: ______________________________

( ) CHECK HERE if you object on the grounds that garnishment in amounts equal to 15% of your

disposable pay would cause financial hardship to you and your dependents. (To arrange voluntary

repayment, contact customer service at the number below.)

You must complete either the enclosed FINANCIAL DISCLOSURE FORM or a Financial Disclosure

Form of your choosing to present your hardship claim. You must enclose copies of earnings and income

records, and proof of expenses, as explained on the form. If your request for an oral hearing is granted,

you will be notified of the date, time, and location of your hearing. If your request for an oral hearing is

denied, the Department will make its determination of the amounts you should pay based on a review of

your written materials.

NOTE: You should also state below any other objections you have to garnishment to collect this debt at

this time.

NOTE: IT IS IN YOUR INTEREST TO REQUEST COPIES OF ALL DOCUMENTATION HELD BY THE

DEPARTMENT BY CALLING THE CUSTOMER SERVICE NUMBER LISTED ON THE ENCLOSED

NOTICE PRIOR TO COMPLETING A REQUEST FOR HEARING.

HEARING REQUEST (Check ONLY ONE of the following)

( ) I want a written records hearing of my objection(s) based on the Department’s review of this written

statement, the documents I have enclosed, and the records in my debt file at the Department.

( ) I want an in-person hearing at the Department hearing office to present my objection(s). I understand

that I must pay my own expenses to appear for this hearing.

I want this In-Person hearing held in: ____ Atlanta, GA, ____ Chicago. IL. ____ San Francisco,

CA. (Check the location you wish for the hearing.)

( ) I want a hearing by telephone to present my objections. (You must provide a daytime telephone

number at which you can be contacted between the hours of 8:00 am to 4:00 pm, Monday through

Friday.) I can be reached at: (

) ______-___________

This is an attempt to collect a debt and any information obtained will be used for that purpose.

v04 (280) Rev. 09/2011

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RFH-AWG DCSI-010

Form Rfh-Awg Dcsi-010 - Request For Hearing