State of Oregon
OFFICE OF VOCATIONAL REHABILITATION SERVICES
Children, Adults and Families
Department of Human Services	WITHDRAWAL OF REQUEST 
             FOR HEARING	

I am withdrawing my request for a hearing.  I understand that I can file a request for a hearing in the future if it is made within 60 calendar days from the date of a VR decision or action with which I disagree.

Date of Hearing Request:  				DRN:  			

Office:  											

Client Name:  										

Client Signature:  									  

Date: