Form DHS-18A "Hearing Request Withdrawal" - Michigan

What Is Form DHS-18A?

This is a legal form that was released by the Michigan Department of Health and Human Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2011;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS-18A by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DHS-18A "Hearing Request Withdrawal" - Michigan

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HEARING REQUEST WITHDRAWAL
Case Name:
Michigan Department of Human Services
Case Number:
Date:
DHS Office:
If you do not understand this, call a DHS office in your area.
Specialist:
DHS employees are prohibited by law from providing legal advice.
Si Ud. no entiende esto, llame a su oficina local del Department of Human Services.
Phone:
La ley prohíbe a los empleados de DHS proporcionar asesoría legal.
Fax:
Specialist ID:
Department of Human Services (DHS) will not
discriminate against any individual or group because
ENTER ADDRESSEE NAME
of race, religion, age, national origin, color, height,
weight, marital status, sex, sexual orientation, gender
ENTER ADDRESSEE CARE OF
identity or expression, political beliefs or disability. If
ENTER ADDRESSEE PO BOX OR STREET
you need help with reading, writing, hearing, etc.,
under the Americans with Disabilities Act, you are
ENTER ADDRESSEE CITY/STATE/ZIP
invited to make your needs known to a DHS office in
your area.
INSTRUCTIONS: Complete all items below. Send completed form in envelope provided or, take it to your local DHS Office.
ATTENTION: Hearing Coordinator
AH Register #
Programs in Dispute
Date Completed DHS-18A received in Local Office
Hearing Request Date
Hearing Scheduled?
Hearing Date and Time (if scheduled)
YES
NO
I DO NOT WANT A HEARING. Please cancel my request for a hearing for the following reason:
(Check the appropriate box below)
I now understand that the action taken by DHS was correct.
DHS has changed its action in my case. I am now satisfied. The change is:
Other. (You must explain)
Signature
Telephone Number
Date Signed
(
)
Street Address or Route Number
City, State, and Zip Code
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight,
marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the
Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
AUTHORITY: MCLA 400.9
COMPLETION: Voluntary
A. H. Approval
Yes
No
Date:
DHS-18A (Rev. 4-11) Previous edition obsolete. MS Word
HEARING REQUEST WITHDRAWAL
Case Name:
Michigan Department of Human Services
Case Number:
Date:
DHS Office:
If you do not understand this, call a DHS office in your area.
Specialist:
DHS employees are prohibited by law from providing legal advice.
Si Ud. no entiende esto, llame a su oficina local del Department of Human Services.
Phone:
La ley prohíbe a los empleados de DHS proporcionar asesoría legal.
Fax:
Specialist ID:
Department of Human Services (DHS) will not
discriminate against any individual or group because
ENTER ADDRESSEE NAME
of race, religion, age, national origin, color, height,
weight, marital status, sex, sexual orientation, gender
ENTER ADDRESSEE CARE OF
identity or expression, political beliefs or disability. If
ENTER ADDRESSEE PO BOX OR STREET
you need help with reading, writing, hearing, etc.,
under the Americans with Disabilities Act, you are
ENTER ADDRESSEE CITY/STATE/ZIP
invited to make your needs known to a DHS office in
your area.
INSTRUCTIONS: Complete all items below. Send completed form in envelope provided or, take it to your local DHS Office.
ATTENTION: Hearing Coordinator
AH Register #
Programs in Dispute
Date Completed DHS-18A received in Local Office
Hearing Request Date
Hearing Scheduled?
Hearing Date and Time (if scheduled)
YES
NO
I DO NOT WANT A HEARING. Please cancel my request for a hearing for the following reason:
(Check the appropriate box below)
I now understand that the action taken by DHS was correct.
DHS has changed its action in my case. I am now satisfied. The change is:
Other. (You must explain)
Signature
Telephone Number
Date Signed
(
)
Street Address or Route Number
City, State, and Zip Code
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight,
marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the
Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
AUTHORITY: MCLA 400.9
COMPLETION: Voluntary
A. H. Approval
Yes
No
Date:
DHS-18A (Rev. 4-11) Previous edition obsolete. MS Word