Iowa Department of Human Services

REQUEST FOR WITHDRAWAL OF APPEAL

 

Name

Program:

Family Investment Program (FIP)/RCA

Food Stamps

Medicaid

State Supplementary Assistance

Services

Vendor or Provider Appeal

Other (identify)

Address:

Appeal No.

I voluntarily wish to withdraw my appeal and request for a hearing before the Iowa Department of Human Services.
My appeal was filed on or about (date).
Added comments, if any:

Date:

Signature:

470-0492 (Rev. 9/00) Back to Appeals