Children, Adults and Families / State of Oregon
Department of Human Services
1DHS1128 CWR (02/10)
In the matter of Claimant
{Claimant name}
{Street address and apt. no.}
{City, state, ZIP code}
Order of Dismissal
OAH Case No.:
DHS Case No.:
1DHS1128 CWR (02/10)
The Department issued a noticeand decision on{date of notice}, and properly served it on the claimant.On behalf of the claimant, the claimant’s representativerequested a hearing on{date of request}.{If true, the Department properly served a Contested Case Notice on date}.The claimant’s representative withdrew the request for hearing on {date of withdrawal of request}.
According to the provisions of OAR 137-003-0672(3)(a), when a party who requests a hearing subsequently withdraws the Request for Hearing, the agency will dismiss the Request for Hearing and the agency order becomes final as if the party never requested a hearing.That is the case here, so the hearing request is dismissed.The Department'sis the final orderin this case.Its factual statements are incorporated as the findings of fact and its legal statements are incorporated as the conclusions of law.
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{Name and title of DHS authorized employee}
Department of Human Services
{Street address}
{City, state, ZIP code}
Notice: You may rescind the withdrawal of your request for hearing up to the tenthwork day following the date this order was mailed to you.Your written rescission and request to have the hearing rescheduled must be received by the {title of DHS authorized employee}at the above-listed address by the end of the tenthwork day. You may request reconsideration or rehearing of this order until the sixtieth day following the date this order was mailed to you.Your written request must be received by the {title of DHS authorized employee} at the above-listed address by the end of the sixtieth day.This request may be granted if you missed the 10-day deadline due to circumstances beyond your control.
Appeal rights: According to the provisions of ORS 183.482, you have the right to appeal the Department’s final order by filing a Petition for Review with the Oregon Court of Appeals. The petition must be filed within sixty days of the date this order was mailed.
Certificate of service:I certify that on {actual date of mailing}, I mailed a true copy in of this Order of Dismissal,by first class mail in a sealed envelope with sufficient postage, addressed to theclaimant,in care of the claimant’s representative, at {address here or above address}and by electronic mail attachment to Rebecca Osborne, Office of Administrative Hearings.
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{Name and title of DHS employee}
Department of Human Services
This document can be provided upon request in alternative formats for individuals with disabilities. Other formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications and other electronic formats. E-mail , call 503-378-3486 (voice) or 503-378-3523 (TTY), or FAX 503-373-7690to arrange for the alternative format that will work best for you.
1DHS1128 CWR (02/10)