Appeal Request Form

Your Information

Please enter your information below.

Only your information is required - Do not add additional persons to this appeal request. Appeals must be requested on an individual basis.

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Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this report(Required):

This field is required.

Appeal Grounds & Rationale

* Appeals must be presented, specifically described, in writing, within three (3) business days of the announcement of the decision.

Case Number (The case number can be found in your outcome letter):(Required) This field is required.

Grounds for Appeal; Not agreeing with the hearing decision is not grounds for appeal.(Required)

There was an error in the hearing procedure New evidence or information material to the case, which was not available at the time of hearing.

You must make at least one selection.

You must explain the grounds for appeal below. It is your burden (responsibility) to prove the stated grounds for appeal. Please provide factual information to support the claim and explain the outcome that you are seeking.(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. Maximum 12 megabytes per file Attachments require time to upload, so please be patient after you click to submit this report. Submit additional information/facts that were not available at time of the hearing. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Your Information

Appeal Grounds & Rationale

Supporting Documentation

Submission