If you believe your state hearing decision is wrong, you may request an administrative appeal by completing this form and signing it. Use of this form is optional and you may also make a request in writing within 15 days to the Bureau of State Hearings by fax, email, mail or by dropping the request off with your caseworker. To request an administrative appeal, please complete the required information below.

* Indicates Required Field

 

Case Number:

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First Name:

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Last Name:

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Address:

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City:

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State:

(Select) Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

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Zip Code:

 

Phone Number with Area Code:

 

Email Address:

 

Hearing Decision Mail Date:

 [None]  

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List the appeal(s) number(s) for administrative appeal:

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I disagree with the state hearing decision because: (select at least one)

The decision is contrary to the weight of the evidence presented
A prejudicial error was committed in the course of the proceeding
The decision relies on an incorrect application of law or rule
   

By typing your electronic signature below, you are saying you are the person requesting the Bureau of State Hearings to process an administrative appeal request for you. Individuals who you have given the right to represent you and sign on your behalf must be designated as an authorized representative on the decision in order to process this request. Otherwise, the authorized representative will need to submit the administrative appeal request by following one of the methods below.

Here are the other ways to send an administrative appeal request and any attachments to ODJFS:

• Email – bsh@jfs.ohio.gov .  Put "Administrative Appeal Request" in the subject line. 
• Fax –  (614) 728-9574
• Mail – ODJFS Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825.
• Contact your caseworker – It is much better to send the request by one of the ways listed above.

 You can ask your local Legal Aid program for free help with your case. Contact your local Legal Aid office by phoning 1-866-LAW-OHIO (1-866-529-6446) or by searching the Legal Aid directory at http://www.ohiolegalhelp.org/find-legal-help/.