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DIAL Administrative Hearings

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

Date Received By Agency

Date Picker


Interpreter/Translator Needed?

Attorney/Representative for Appellant (if any)

Jurisdictional and Other Authority

Other Important Information

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Time Needed for Hearing

Type of Hearing