Free lb0896AppealsNewAddress.pmd - Tennessee


File Size: 40.9 kB
Pages: 1
Date: December 28, 2007
File Format: PDF
State: Tennessee
Category: Workers Compensation
Author: CC30218
Word Count: 124 Words, 1,772 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.tn.us/labor-wfd/Appeals/forms/LB-0896.pdf

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STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Employment Security Appeals Operations 220 French Landing Drive Nashville, Tennessee 37243
Telephone: (615) 741-1857 Facsimile: (615) 741-8933

Request to Reschedule Hearing

Claimant's Social Security Number _____________________________

Docket Number ___________________________

Claimant's Name _________________________________

Employer's Name __________________________________

Street Address ___________________________________

Street Address ____________________________________

City ____________________ State ____

Zip __________

City ______________________ State ____ Zip _________

Claimant's Telephone ______________________________

Employer's Telephone ______________________________

Please reschedule the:

Appeals Tribunal

Board of Review

hearing currently set for

_______________________ (time)

on

_________________________ (date)

with

___________________________________________ (hearing officer)

I have a significant conflict with the date/time for the hearing. (Please describe) ____________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Date ________________________

Signature _____________________________________ Title __________________________________________ (if employer)

Note:

Absent an emergency, a party requesting a reschedule of an Appeals Tribunal hearing must make its request at least 48 hours before the date and time of the hearing.

LB-0896