Appellant Name _______________________________ Appeal No. ____________________
Presiding Officer _______________________________ Date ________________________
TO OFFICE OF ADMINISTRATIVE HEARINGS:
I, _________________________________________________________, residing at
(Appellant/Representative)
____________________________________________________________________________________,
(Address)
hereby wish to inform you that I am withdrawing my appeal to the Office of Administrative
Hearings which was made on __________________________ for the following
reasons:
(Date)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I am taking this action voluntarily.
_________________________________________
(Signature of Applicant)
***PLEASE RETURN THIS FORM TO:
Office of Administrative Hearings
1020 S Kansas Avenue
Topeka, Kansas 66612-1327
Office of Administrative Hearings
Department of Administration