I.

Background Information

A.

Name of Respondent:

Principal office address:

Telephone:  (Area Code)

B.

Name Respondent's Representative:

Title

Office Address

Telephone:  (Area Code)

Check the allegations of the appeal petition which you dispute:

Respective Paragraph

Not

of Appeal Petition

Disputed

Disputed

I C

II A

II B

II C

II D 1

II D 2

II D 3

II D 3 a

II D 3 a(1)

II D 3 a(2)

II D 3 a(3)

II D 3 a(4)

II D 3 a(4) (a)

II D 3 a(4) (b)

II D 3 a(4) (C)

II D 4

II D 4 a

II D 4 a(1)

II D 4 a(1) (b)

II D 4 a(1) (b) (1)

II D 4 a(1) (b) (2)

II D 4 a(1) (b) (3)

II D 4 a(1) (b) (4)

II D 4 a(1) (b) (5)

II D 5

II D 5 a

II D 5 b

II D 5 c

II D 5 d

II D 5 e

II D 5 f

II D 5 g

II D 5 h

II D 5 i

II D 5 j

II D 5 k

III A

III B

III C

III C(1)

III C(2)

III D

III D(1)

III D(2)

III D(3)

III D(3) (a)

III D(3) (b)

III D(3) (b) (i)

III D(4)

III D(5)

III D(6)

III E

III E(1)

III F

III F(1)

III F(2)

III G

III G(1)

III G(2)

III H

III H(1)

III H(2)

III H(3)

III I

III J

III J(1)

III K

For each disputed allegation, explain in detail the basis for your position and provide supporting documentation as one or more exhibits to this response.

RESPONDENT:

BY:

Representative

ACKNOWLEDGEMENT

I, the undersigned, do hereby certify that I have read the statements and facts set forth in the foregoing Response of State Agency and state that they are true to the best of my knowledge and belief.

Subscribed and sworn to before me

this

day of

, 19

Notary Public