Fax Cover Sheet - Hardship Request printable pdf download

Fax Cover Sheet - Hardship Request

FAX COVER SHEET

Hardship Request

Date:

Sender:

To:

Office Name:

Bill Brautigam

Office Name:

Address:

APD Central Office

Address:

City:

500 Summer St NE E12

City:

State:

Zip:

Salem

State:

Zip:

Phone No.:

97301

Phone No.:

Fax No.:

503.947.5204

Fax No.:

Total Pages:

503.378.7823

Re:

Application for hardship waiver

Potential APS case

Confidentiality Notice: The information contained in this facsimile may be confidential and

legally privileged. It is intended only for use of the individual named. If you are not the

intended recipient, you are hereby notified that the disclosure, copying, distribution, or taking

of any action in regards to the contents of this fax – except its direct delivery to the intended

recipient – is strictly prohibited. If you have received this fax in error, please notify the sender

immediately and destroy this cover sheet along with its contents, and delete from your system,

if applicable.

DHS 2009 (REV 9/2003)

Fax Cover Sheet - Hardship Request