Form Cssd 04-1916 - Withdrawal From Formal Hearing Form - 2007

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Please Reply To:
Alaska Department of Revenue
CSSD, MS 24
Child Support Services Division
th
550 W. 7
Ave., Suite 310
Anchorage, AK 99501-6699
www. childsupport.alaska.gov
Withdrawal from Formal Hearing
Date: ________________
CSSD Case No.: _________________
I hereby withdraw from the Formal Hearing (AS 25.27.190) and accept the
Administrative Review Decision dated _________________________, as written.
Print Name
Signature
SUBSCRIBED AND SWORN to before me this
day of
, 20
.
___________________________________
Notary Public in and for Alaska
My commission expires: _________
CSSD 04-1916 (Rev 03/9/07)
MAT-SU: (907) 357-3550
TOLL FREE (In-state, outside Anchorage): (800) 478-3300
SOUTHEAST: (907) 465-5887
ANCHORAGE: (907) 269-6900
FAX: (907) 269-6813 or 6914
FAIRBANKS: (907) 451-2830
TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894

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