Form H4856, Request for Another Appointment for Administrative Disqualification Hearing

Effective Date
06/2005
Document
Document
H4856.doc (145.5 KB)
Document
H4856.pdf (38 KB)

Instructions

Updated: 9/2000

Purpose

  • To notify the hearing officer that the household member will be unable to attend the hearing on the scheduled date.
  • To enable the household member to request a different hearing date.

Procedure

When to Prepare

The household member or representative completes Form H4856 when the household member receives Form 4851, Notice of Administrative Disqualification Hearing, and he wishes to change the hearing date.

Number of Copies

Complete an original Form H4856.

Transmittal

Send Form H4856 to the household member with:

  • Form 4851, Notice of Administrative Disqualification Hearing;
  • Form 4855, Statement of Household Member's Rights in Administrative Disqualification Hearing; and
  • An envelope addressed to the hearing officer.

The household member or representative completes Form H4856 and mails it back to the hearing officer if the household member wishes a different hearing date. He must request a different hearing date at least 10 days before the scheduled hearing.

Form Retention

The hearing officer keeps the form for six months after the appeal is completed.

DETAILED INSTRUCTIONS

From — Enter the name and mailing address of the household member.

To — Type the name and office address of the hearing officer.

The remainder of the form is self-explanatory.