Form Pde 338 R-4 - Request For Appeal - Pennsylvania Department Of Education printable pdf download

pennsylvania

DEPARTMENT OF EDUCATION

Instructions for Appeal: Act 48/Act 45

In accordance with 1205.2(i) of the Public School Code (Act 48 of 1999)

Form PDE 338 R-4

This form is used to file an appeal of the Department’s Notice of Inactive Certification for failure to meet Continuing

Professional Development requirements. Mail an original and two copies of this completed form or a signed written

request for appeal (including name, social security number, address, telephone number, statement of reason(s) for

appeal, photocopy of denial letter, and other supporting documentation) to: Pennsylvania Department of Education, DPD

Act 48/Act 45 Appeals, 333 Market Street – 3rd Floor, Harrisburg, PA, 17126-0333.

PRINT IN CAPITAL LETTERS WITH DARK BLUE OR BLACK INK ONLY

1. Print your Last Name, First Name and Middle Initial.

2. Print your complete address, and enter your Zip Code.

3. Print your former name(s), if applicable, beginning with the most recent.

4. Enter your Social Security Number. Failure to provide SSN may result in a delay of appeal processing.

5. Enter your Date of Birth (Month, Day, Year).

6. Print M or F in the correct box for male or female.

7. Enter your telephone numbers (Home and Daytime) in case we need to contact you.

8. Select the reason for appeal.

9. Please submit the following documentation:

a. Request Form PDE 338 R-4 or written request for appeal

b. Copy of teaching certificate

c. Copy of PDE Notice of Inactive Certification

d. Brief statement explaining your reason(s) for your appeal, including the factual and legal basis for the

appeal. You must state a reason for appeal in order for your appeal to be considered.

e. Other necessary documentation to support your appeal.

10. Applicant Statement. Your signature on this form or on your written request verifies that all of the information

provided is cor rec t and true. Misrepresentation/falsification of any statement or document may result in the

revocation of your Pennsylvania certificate.

All appeals must be received by the Division of Planning within 30 days of date of Notice of Inactive Certification.

Mail the application and supporting documents to: Pennsylvania Department of Education, DPD Act 48/Act 45 Appeals,

333 Market Street – 3rd Floor, Harrisburg, PA, 17126-0333.

NOTE: For credit discrepancies (credits/hours taken within the 5-year period but not on record with the Department), PDE

338 R-4 may not always be necessary.

1. View and print your continuing professional education records from the

Professional Education Record

Management System (PERMS)

to determine the specific discrepancy in credits/hours reported to the Department

(see link to Reporting System on left navigation).

2. Contact the approved provider(s) concerning specific records where discrepancies exist. If you have any

questions, please check the PDE website at

Revised October 2017

Form Pde 338 R-4 - Request For Appeal - Pennsylvania Department Of Education