DIAL Administrative Hearings

adminhearings@dia.iowa.gov

Wallace State Office Building, 502 E Ninth Street, Third Floor, Des Moines, IA 50319

(515) 281.6468

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)

Click Here to Upload

Time Needed for Hearing

1 hour

2 hours

Half day

Full day

Type of Hearing

In-person

Telephone

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