School Employee Request for Review/Notice of Appeal 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1, where you will provide your personal information. Clearly indicate whether you are an employee, former employee, or dependent by selecting the appropriate option.
3. Fill in your last name, first name, middle initial, and Social Security number. Ensure that all details are accurate to avoid processing delays.
4. In Section 2, if applicable, include information about any other enrollees related to your appeal. This may involve entering their names and Social Security numbers.
5. Section 3 requires a detailed description of your request for review or appeal. Be as specific as possible about the situation leading to your appeal.
6. Finally, sign and date Section 9 to confirm that the information provided is true and complete before submitting the form to the appropriate office.

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