STATE AGENCY INFORMAL HEARING REQUEST

REQUEST FOR INFORMAL HEARING / CONFERENCE

Date: [__/__/____]

VIA: ☐ Certified Mail ☐ Email ☐ Electronic Filing ☐ Hand Delivery

TO:
[________________________________]
State Agency Name
Informal Hearing Unit / Alternative Dispute Resolution Office
[________________________________]
[________________________________]
[________________________________]

FROM:
Petitioner Name: [________________________________]
Address: [________________________________]
City, State, ZIP: [________________________________]
Telephone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

RE: Request for Informal Hearing / Conference
Case/Matter Number: [________________________________]
Date of Agency Action/Notice: [__/__/____]

SECTION 1: TYPE OF PROCEEDING REQUESTED

Petitioner requests the following type of proceeding:

☐ Informal Conference (pre-hearing meeting with agency staff)

☐ Informal Hearing (summary proceeding without formal evidentiary rules)

☐ Alternative Dispute Resolution (ADR)
☐ Mediation
☐ Arbitration (binding)
☐ Arbitration (non-binding)
☐ Settlement conference
☐ Early neutral evaluation

☐ Paper Hearing (decision based on written submissions only)

☐ Other: [________________________________]

SECTION 2: IDENTIFICATION OF MATTER

Agency Action at Issue

Type of Action:
☐ License/Permit Denial
☐ License/Permit Revocation/Suspension
☐ Citation/Notice of Violation
☐ Proposed Penalty/Fine - Amount: $[________________________________]
☐ Denial of Benefits/Services
☐ Permit Condition Dispute
☐ Contract Dispute with Agency
☐ Other: [________________________________]

Date of Agency Action: [__/__/____]
Date Notice Received: [__/__/____]
Response/Appeal Deadline: [__/__/____]

Description of Agency Action:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Parties

Petitioner (Affected Party):
Name: [________________________________]
Type: ☐ Individual ☐ Business Entity
If Entity, Type: ☐ Corporation ☐ LLC ☐ Partnership ☐ Other: [________________________________]
License/Permit Number (if applicable): [________________________________]

Agency/Division:
[________________________________]
Contact Person: [________________________________]
Title: [________________________________]
Telephone: [________________________________]
Email: [________________________________]

SECTION 3: ELIGIBILITY FOR INFORMAL PROCEEDINGS

Statement of Eligibility

Petitioner believes this matter is appropriate for informal proceedings because:

☐ No material facts are in dispute (only issues of law or policy are at issue)

☐ The disputed facts are limited and can be resolved through documentary evidence

☐ The amount in controversy is: $[________________________________]
(Note: Many agencies have monetary thresholds for informal proceedings)

☐ The parties have agreed to attempt informal resolution

☐ The agency's rules authorize informal proceedings for this type of matter

☐ Other: [________________________________]

Applicable Rule/Statute Authorizing Informal Hearing:
[________________________________]

SECTION 4: STATEMENT OF ISSUES

Issues to be Addressed

Issue 1:
[________________________________]
[________________________________]
[________________________________]

Issue 2:
[________________________________]
[________________________________]
[________________________________]

Issue 3:
[________________________________]
[________________________________]
[________________________________]

Statement of Petitioner's Position

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

SECTION 5: STATEMENT OF FACTS

Undisputed Facts

The following facts are not in dispute:

1. [________________________________]
2. [________________________________]
3. [________________________________]
4. [________________________________]
5. [________________________________]

Disputed Facts (if any)

SECTION 6: EFFORTS TO RESOLVE INFORMALLY

Prior Contact with Agency

☐ Petitioner has attempted to resolve this matter informally.

Date(s) of Contact: [________________________________]
Person(s) Contacted: [________________________________]
Method: ☐ Telephone ☐ Email ☐ Letter ☐ In-Person

Outcome of Prior Discussions:
[________________________________]
[________________________________]
[________________________________]

Remaining Issues

Issues resolved through prior discussions:
[________________________________]

Issues remaining in dispute:
[________________________________]

SECTION 7: PROPOSED RESOLUTION

Petitioner proposes the following resolution:

☐ Withdrawal/Reversal of Agency Action
The agency should withdraw its action because:
[________________________________]

☐ Modification of Agency Action
The agency should modify its action as follows:
[________________________________]

☐ Reduction of Penalty
Reduce penalty from $[________________________________] to $[________________________________]
Based on: [________________________________]

☐ Conditional Approval
Grant approval subject to the following conditions:
[________________________________]

☐ Compliance Plan
Allow implementation of the following compliance plan:
[________________________________]

☐ Payment Plan
Allow payment of penalty over [____] months: $[________________________________]/month

☐ Other Resolution:
[________________________________]

SECTION 8: SUPPORTING INFORMATION

Documents to be Presented

Witnesses (if needed)

SECTION 9: WAIVER OF FORMAL HEARING RIGHTS

☐ WAIVER REQUESTED: Petitioner understands that by requesting an informal hearing, Petitioner may be waiving certain rights that would be available in a formal evidentiary hearing, including:

• Right to formal discovery
• Strict application of rules of evidence
• Right to cross-examine witnesses
• Right to subpoena witnesses
• Other rights: [________________________________]

☐ RESERVATION OF FORMAL HEARING RIGHTS: Petitioner requests an informal hearing without waiving the right to a formal hearing if the informal proceeding does not result in a satisfactory resolution.

☐ CONDITIONAL REQUEST: This request for informal proceedings is conditioned upon:
[________________________________]

SECTION 10: ALTERNATIVE DISPUTE RESOLUTION

If Requesting Mediation

☐ Petitioner requests mediation to resolve this matter.

Statement of Good Faith:
Petitioner enters this mediation process in good faith with the intent to reach a mutually acceptable resolution.

Authority to Settle:
☐ Petitioner has full authority to reach a binding settlement.
☐ Petitioner must obtain approval from: [________________________________]

Preferred Mediator Qualifications:
[________________________________]

Confidentiality:
Petitioner understands that mediation communications are confidential and cannot be used in subsequent proceedings.

If Requesting Arbitration

☐ Petitioner requests arbitration.

Type:
☐ Binding Arbitration - Petitioner agrees to be bound by the arbitrator's decision.
☐ Non-Binding Arbitration - Petitioner reserves the right to reject the arbitrator's decision and proceed to formal hearing.

Issues to be Arbitrated:
[________________________________]

SECTION 11: SCHEDULING

Availability

Preferred Date(s) for Hearing/Conference:
1. [__/__/____]
2. [__/__/____]
3. [__/__/____]

Unavailable Dates:
[________________________________]

Preferred Time: ☐ Morning ☐ Afternoon ☐ No preference

Preferred Location:
☐ Agency Office at: [________________________________]
☐ By Telephone
☐ By Video Conference
☐ Other: [________________________________]

Estimated Time Needed: [____] hours

Special Accommodations

☐ Interpreter Required - Language: [________________________________]
☐ ADA Accommodations Required - Specify: [________________________________]
☐ Other: [________________________________]

SECTION 12: STATE-SPECIFIC REQUIREMENTS

California

Governing Law:
- Government Code § 11445-11445.60 (Informal Hearing Procedures)
- Individual agency regulations

Types of Informal Proceedings:
- Conference Hearing (Gov. Code § 11445.30)
- Emergency Decision (Gov. Code § 11445.30)

Requirements:
- Written request stating willingness to waive formal hearing
- May be converted to formal hearing if disputed facts require

Texas

Governing Law:
- Government Code Chapter 2001.056 (Informal Disposition)
- SOAH Rules 1 TAC § 155.505

ADR Services:
- State Office of Administrative Hearings offers mediation
- Parties may agree to informal disposition at any time

Florida

Governing Law:
- Florida Statutes § 120.57(2) (Informal Proceedings)
- No disputed issues of material fact required

Requirements:
- Must not involve disputed facts
- Agency head or designee conducts informal hearing
- Parties may present written or oral evidence

New York

Governing Law:
- State Administrative Procedure Act § 301
- Agency-specific informal procedures

Options:
- Many agencies offer settlement conferences
- Some offer mediation programs

SECTION 13: CERTIFICATION

I, the undersigned Petitioner, hereby certify that:

1. The statements made in this request are true and correct to the best of my knowledge.

2. This request is made in good faith for the purpose of resolving the matter at issue.

3. I understand the nature of informal proceedings and the rights I may be waiving.

4. I am authorized to represent the party named in this request.

5. I agree to participate in good faith in any informal proceeding granted.

6. I understand that if informal resolution is not achieved, the matter may proceed to formal hearing.

Petitioner Signature: [________________________________]
Printed Name: [________________________________]
Title (if applicable): [________________________________]
Date: [__/__/____]

SECTION 14: REPRESENTATIVE INFORMATION

☐ Petitioner is self-represented

☐ Petitioner is represented by:

Name: [________________________________]
Title/Relationship: ☐ Attorney ☐ Authorized Representative ☐ Other: [________________________________]
Bar Number (if attorney): [________________________________]
Firm/Organization: [________________________________]
Address: [________________________________]
Telephone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

Please direct all communications to the representative above.

Representative Signature: [________________________________]
Date: [__/__/____]

SECTION 15: CONSENT TO INFORMAL PROCEEDINGS

For Matters Requiring Agency Consent

Agency Response (for agency completion):

☐ Request for informal hearing is GRANTED.
- Date scheduled: [__/__/____]
- Time: [________________________________]
- Location: [________________________________]
- Assigned Hearing Officer: [________________________________]

☐ Request for informal hearing is DENIED.
- Reason: [________________________________]
- Petitioner may file for formal hearing by: [__/__/____]

☐ Request for ADR is GRANTED.
- Type: [________________________________]
- Date scheduled: [__/__/____]
- Mediator/Arbitrator: [________________________________]

Agency Representative Signature: [________________________________]
Title: [________________________________]
Date: [__/__/____]

REQUEST CHECKLIST

☐ Request form completed
☐ Matter number/case number included
☐ Type of proceeding requested is specified
☐ Issues clearly stated
☐ Proposed resolution stated
☐ Supporting documents attached or listed
☐ Scheduling information provided
☐ Request signed and dated
☐ Copy retained for records
☐ Sent to correct agency address
☐ Filing deadline verified

SUBMISSION INSTRUCTIONS

Submit Request To:
[________________________________]
[________________________________]
[________________________________]

Reference: Case/Matter No. [________________________________]

Questions About Informal Hearing Procedures:
[________________________________]
[________________________________]

NOTE: Informal hearing procedures vary significantly by state and agency. Not all matters are eligible for informal proceedings. An informal hearing may not provide all the procedural protections of a formal hearing. Consult with an attorney to determine whether an informal proceeding is appropriate for your situation and to understand what rights you may be waiving. This template provides general guidance only and does not constitute legal advice.