State of Oregon Department of Human Services




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State of Oregon

Department of Human Services




In the matter of Claimant
{Claimant name}

{Street Address & Apt #}

{City, State, Zip Code}


Order of Dismissal



The claimant requested a hearing on {Date of Request}, but 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, so the hearing request is dismissed.

________________________________________

{Hearings Representative},

Department of Human Services Hearing Representative

{Street Address}

{City, State Zip}


Notice: You may rescind the withdrawal of your request for hearing up to the 10th work 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 Hearing Representative at the above-listed address and postmarked no later than the 10th work day. You may request reconsideration or rehearing of this order until the 60th day following the date this order was mailed to you. Your written request must be received by the Hearing Representative at the above-listed address and postmarked no later than the 60th 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 60 days of the date this order was mailed.
Certificate of Service: I certify that on {Actual Date of Mailing}, I mailed in a sealed envelope a true copy of this Order of Dismissal, by first-class mail with sufficient postage, addressed to the Claimant at the above-listed address.

________________________________________

{Hearings Representative},

Hearing Representative



DHS 1126 (rev. 06/14)


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