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DQUSaT.IiTAZ:::nC-e") <br /> DSS-H6 NORTH CAROLINA <br /> DEPARTMENT OF HUMAN RESOURCES <br /> DIVISION OF SOCIAL SERVICES <br /> REQUEST FOR STATE APPEAL <br /> Appellant 7/4■Cie 64- m, County (97.- <br /> St. Address ( j Program ___4700 Of <br /> City, St., Zip _ C., ->frd ,;Account No. <br /> Date of Request Ar Case No. 7 ? <br /> Appellant's reason for request: Alla0 /0/ /41fiei, <br /> A.- Zh■ <br /> Date of local appeal: request hearing , decision - <br /> Is a representative frrm State Medical Review Unit requested? <br /> Is client represented y legal counsel? If so, state name and address; <br /> Ethnic Group (For Federal statistical reporting only) : <br /> White , Black , American Indian , Other (Specify) <br /> PLEASE ATTACH A COPY op THE FOLLOWING: 1. Local appeal hearing decision, 2. Medicals dated <br /> within the last year fbr appeal cases involving a disability or incapacity, 3. Most recent <br /> State Medical Review Uhit rejection, if applicable. <br /> Worker 111 on A <br /> AC Air <br /> Director ± Iatt <br /> ' 1/____ 2c741 <br /> Supervisor Date 2 2.- <br /> Original and Copies to: Board of County Commissioners <br /> one copy to: Director Appellant <br /> Division of Social Services County Department of Social Services <br /> Department of Human Resources <br /> 325 North Salisbury St. <br /> Albemarle Building <br /> Raleigh,INorth Carolina 27611 <br /> 4/' <br />