DHS-8334-ENG 10-24 (1.0.2)

Cancel Appeal to State Agency

Use this form to cancel your appeal. Appeals can ONLY be withdrawn by you, the appellant, or by your Authorized Representative. Agency representatives cannot cancel your appeal. If you have questions or need help, call the Minnesota Department of Human Services' Appeals Division at 651-431-3600.

Appeal

Please provide as much information as you can about your appeal.

DOCKET NUMBER

HUMAN SERVICES JUDGE

HEARING DATE

Who is the appeal about (the appellant)?

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

Request

Are you the appellant?

Yes

Please explain who you are.

What is your telephone number?

No phone number

What is your email address?

I want to cancel the appeal because:

Please provide any more information you would like about why you are canceling the appeal.

Sign and submit

By signing this form, I am asking the Minnesota Department of Human Services' Appeals Division to stop my appeal and cancel any scheduled hearing.

ELECTRONIC SIGNATURE

DATE

Form Language