Appendix A - Petition for Contested Case Hearing Sample FormatBOARD OF TRUSTEES EMPLOYEES' RETIREMENT SYSTEM STATE OF HAWAII
| ) | |
| In the Matter of | ) | DOCKET No.: |
| ) | (To be filled in by agency) |
| _______________________ | ) | |
| (Petitioner's first and last name) | ) | PETITION FOR CONTESTED CASE |
| ) | HEARING |
| Petitioner, | ) | |
| ) | Attachments or Exhibits: |
| for a Contested Case Hearing. | ) | |
| ) | 1. ________________________ |
| ) | |
| ) | 2. _________________________ |
| ) | |
| ) | 3. ________________________ |
| ) | |
| ) | 4. ________________________ |
| _______________________ | ) | |
PETITION FOR CONTESTED CASE HEARING
1. PETITIONER'S INFORMATIONA. Petitioner's Name:(Type or write in the Petitioner's full legal name.)B. Petitioner's Mailing Address:(Type or write in the Petitioner's complete mailing address. Unless the Petitioner is represented by an attorney, all notices and pleadings in this proceeding will be mailed to this address.)C. Petitioner's Telephone Number:(Type or write in the Petitioner's complete telephone number.)D. Petitioner's Fax Number:(Type or write in the Petitioner's complete fax number if available.)E. Petitioner's E-Mail Address:(Type or write in the Petitioner's e-mail address if available.)2. STATEMENT OF PETITIONER'S INTEREST, REASONS FOR SUBMITTING PETITION AND ISSUESA. Nature of Petitioner's Interest:(Briefly state the nature of Petitioner's interest in this Petition. For example: "I am a member of the Employees' Retirement System," or "I am a beneficiary of the Employees' Retirement System.")B. Petitioner's Reasons for Submitting Petition:(Briefly state Petitioner's reasons for filing this Petition. For example, "The Employees' Retirement System has improperly calculated my service credits.")C. Petitioner's Statement of Issues:(Briefly describe all of the issues being raised in this Petition including all of the claims being made under the Petition. For example "Under Hawaii Revised Statutes § 88-132, I am claiming military service credit because I was an active member of the Employees' Retirement System when I went on military leave in March 1972.")3. STATEMENT OF RELEVANT FACTS(In this section of the Petition, state all of the facts that Petitioner believes are relevant to the issues being raised in the Petition, including a chronology of events, if that would be helpful to understanding the issues. If Petitioner is disputing a denial of retirement benefits service credits, or some other entitlement, state the date of the denial, the date when you became aware of the denial, and how you discovered or learned of the denial.)4. STATEMENT OF LEGAL REASONS SUPPORTING THE PETITION(In this section of the Petition, state the legal reasons supporting Petitioner's claims or positions on issues raised in the Petition. If the legal reasons include any court decisions or other legal authorities, identify them and state how they support Petitioner's claims or positions.)5. PETITIONER'S POSITION ON STATUTES, RULES, AND ORDERS IN QUESTIONA. Statutes:(Identify any statutes which are involved in the Petition and Petitioner's position on those statutes. For example, if Petitioner is disputing a denial of retirement benefits, identify all statutes under which Petitioner believes that those benefits should be granted. If Petitioner is contesting the interpretation of any statutes by the Employees' Retirement System (ERS), identify the statutes in question and provide Petitioner's interpretation of those statutes.)B. Rules:(Identify any ERS or other agency rules which are involved in the Petition., For example, if Petitioner is claiming some right or benefit, identify all rules which support Petitioner's claim. If Petitioner is claiming that any ERS rules are invalid, identify those rules and state the reasons that Petitioner claims they are invalid. If Petitioner is contesting the ERS' interpretation of any rules, identify the rules, and provide Petitioner's interpretation of those rules. If no ERS or other agency rules are involved, state "None" or "Not Applicable".)C. Orders:(Identify any court, ERS or other agency orders which Petitioner claims are involved in the Petition. For example, if Petitioner is claiming some right or benefit, identify all orders which support Petitioner's claim. If Petitioner is claiming that a prior ERS order is invalid, identify the order, and state the reasons why Petitioner claims it is invalid. If Petitioner is contesting the ERS' interpretation of any orders, identify the orders, and provide Petitioner's interpretation of those orders. Attach a copy of each order identified to this Petition. If no orders are involved, state "None" or "Not Applicable".)6. RELIEF REQUESTED(In this section, state exactly and completely what relief or remedy Petitioner is seeking from the Board of Trustees of the Employees' Retirement System under this Petition.)
7. NAMES OF OTHER PARTIES OR POTENTIAL PARTIES(State the full names and addresses, if known, of any persons, firms, or other entities that Petitioner believes should be made parties to this proceeding or who are potentially parties to this proceeding. If there are no other parties or potential parties, state "None" or "Not Applicable.")
8. APPEARANCE ON BEHALF OF PETITIONERIf the Petitioner is being represented by an attorney or other agent in this proceeding provide the name, mailing address, telephone number, fax number (if available), and e-mail address (if available) of the attorney or other agent below. By filling in this information Petitioner is authorizing the Employees' Retirement System to provide all notices and other documents in this proceeding to the attorney or agent identified below instead of to the Petitioner.
E. E-Mail Address:This Petition is being filed pursuant to Section 91-9, Hawaii Revised Statutes, and Hawaii Administrative Rules Chapter 6-23. I declare under penalty of perjury that the facts alleged in this Petition are, to the best of my knowledge, true and correct.
DATED:(Type or write in Petitioner's city, state, and the date the Petition is signed)
By___________________________________
Petitioner (signature)