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Administrative Hearings Transmittal Form

Please complete the entire form.

Transmitting Agency

Agency

Agency email

Agency Phone Number

Address

City

State

Zip Code

Transmitting Officer Name, Title

Agency File/Docket/Reference Number(s)

Date Received By Agency

Appellant

Name

Appellant email

Appellant phone number

Address

City

State

Zip Code

Interpreter/Translator Needed?

Yes

Language needed

Attorney/Representative for Appellant (if any)

Name

Attorney/rep email

Attorney/rep phone number

Address

City

State

Zip Code

Jurisdictional and Other Authority

Iowa Code Section(s)

Iowa Administrative Rule(s)/Federal Regulation(s)

Other Important Information

Statement of Issues

Scheduling

Other

Upload File(s) (if necessary)

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Time Needed for Hearing

1 hour

2 hours

Half day

Full day

Type of Hearing

In-person

Telephone

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