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Effective Date: 




Updated: 3/2019



To notify and provide the applicant and/or client with the copies of documents the hearing officer will consider during the fair hearing.


When to Prepare

Complete this form and attach to copies of all supporting documents that will be entered into evidence during the fair hearing. Send this packet to the appellant and/or the authorized representative within five calendar days from the date Form H4803, Notice of Hearing, is received by the agency representative.

Number of Copies

Complete an original for the appellant and make a copy for the authorized representative (if applicable). Place one copy in the client's case record.


Send Form H4837 with copies of the documents within five calendar days from the date Form H4803 is received by the agency representative via mail to the appellant and/or the authorized representative.

Detailed Instructions

Date – Enter the date the form was completed.

Local Office – Enter the name of the agency contact/representative completing the form.

Office Address – Enter the office address of the agency contact.

Telephone Number and Area Code – Enter the office telephone number of the agency contact.

Case Numbers – Enter all appropriate case number(s) being appealed in the appropriate field(s).

Client Name and Address – Enter the client's name and address in the appropriate field.

If the appellant has an authorized representative, mail a copy of the packet and Form H4837 addressed to the authorized representative using the following format:

Appellant's first and last name
c/o Authorized representative's first and last name
Authorized representative's address line 1
Authorized representative's address line 2
Authorized representative's city, state, ZIP code