Alaska > Statewide > Child Support Services Division
Withdrawal From Formal Hearing 04-1916 - Alaska
| Withdrawal From Formal Hearing Form. This is a Alaska form and can be used in Child Support Services Division Statewide . |
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STATE OF ALASKA DEPARTMENT OF REVENUE CHILD SUPPORT SERVICES DIVISION SEAN PARNELL, GOVERNOR Please Reply To: CSSD, MS 24 550 WEST 7th AVE., SUITE 310 ANCHORAGE, AK 99501-6699 Formal Hearing Withdrawal and Consent CSSD Case No.: I, ______________________________, the Appellant in this matter, hereby withdraw my request for Formal Hearing under AS 25.27.190 and: Accept the order dated ____________ as written. Consent to an ongoing child support obligation in the amount of $_______________ per month, effective _______________; plus arrears totaling $_______________ for the period beginning _______________ through _______________. Consent to a modified child support obligation in the amount of $_______________ per month, effective _______________. I understand that this settles all matters on appeal and no hearing will be held. Appellant Signature Date I, ______________________________, the Respondent in this matter, consent to the terms listed above. I understand that this settles all matters on appeal and no hearing will be held. Respondent Signature Date Approved by: CSSD Representative Signature Date CSSD 04-1916 (2/09/2012) MAT-SU: (907) 357-3550 TOLL FREE (In-state, outside Anchorage): (800) 478-3300 SOUTHEAST: (907) 465-5887 ANCHORAGE: (907) 269-6900 FAX: (907) 787-3220 FAIRBANKS: (907) 451-2830 TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894 American LegalNet, Inc. www.FormsWorkFlow.com
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