Form Cssd 04-1916 - Formal Hearing Withdrawal And Consent

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SEAN PARNELL, GOVERNOR
STATE OF ALASKA
Please Reply To:
Print Form
DEPARTMENT OF REVENUE
CSSD, MS 24
th
550 WEST 7
AVE., SUITE 310
CHILD SUPPORT SERVICES DIVISION
ANCHORAGE, AK 99501-6699
Formal Hearing Withdrawal and Consent
00
CSSD Case No.:
I, ______________________________, the Appellant in this matter, hereby withdraw my request for
Formal Hearing under AS 25.27.190 and:
Accept the order dated ____________ as written.
Consent to an ongoing child support obligation in the amount of $_______________ per
month, effective _______________; plus arrears totaling $_______________ for the period
beginning _______________ through _______________.
Consent to a modified child support obligation in the amount of $_______________ per
month, effective _______________.
I understand that this settles all matters on appeal and no hearing will be held.
Appellant Signature
Date
I, ______________________________, the Respondent in this matter, consent to the terms listed
above. I understand that this settles all matters on appeal and no hearing will be held.
Respondent Signature
Date
Approved by: CSSD Representative
Signature
Date
CSSD 04-1916 (2/09/2012)
MAT-SU: (907) 357-3550
TOLL FREE (In-state, outside Anchorage): (800) 478-3300
SOUTHEAST: (907) 465-5887
ANCHORAGE: (907) 269-6900
FAX: (907) 787-3220
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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