PLEASE PRINT CLEARLY OR TYPE STATE OF NORTH CAROLINA

PLEASE PRINT CLEARLY OR TYPE STATE OF NORTH CAROLINA

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PLEASE PRINT CLEARLY OR TYPE
STATE OF NORTH CAROLINA
IN THE OFFICE OF
ADMINISTRATIVE HEARINGS
COUNTY OF (1)                                                                        
CSE

(2)
                                                                                                                             
)
)
(your name) PETITIONER,
)
)
PETITION FOR A
v.
)
CONTESTED CASE HEARING
)
Arising under N.C. Gen. Stat. Ch. 105A,
N. C. Department of Health and Human Services,
)
N.C. Gen. Stat. § 110-140 and 45 C.F.R. 303.72
Division of Social Services, Child Support Enforcement Section
)
RESPONDENT.
)

I hereby ask for a contested case hearing as provided for by North
Carolina General Statute § 150B-23 because the Respondent has deprived
me
of property and has substantially prejudiced my rights.
(3) Date you received notice of tax intercept:
(4) My appeal is based upon the following (check all that apply):
Amount owed is incorrectly stated
I am not the person who owes the duty of support
Other (specify)
(5) The facts supporting my appeal are as follows:
(If more space is needed, attach additional pages)
(6) Because of these facts, the Respondent has (check all that apply):
              exceeded its authority or jurisdiction;
               acted erroneously;
                   failed to use proper procedure;
              acted arbitrarily or capriciously; or
 _            failed to act as required by law or rule.
(7) Your IV-D number _____________________________________ Your MPI
number _____________________________________________
(8) Date: (9) Telephone number: ( )
(10) Print your full mailing address:
__________________________________________________________________________________________
(street address/PO Box) (city) (state) (zip)
Print your e-mail
address:___________________________________________________________________________________________________
(11)Print your name:
(12) Your signature:
You must mail or deliver a COPY of this Petition to the State agency
named on this form; please indicate below.
CERTIFICATE OF SERVICE
I certify that this Petition has been served on:
Lisa G. Corbett, General Counsel
N.C. Department of Health and Human Services
2001 Mail Service Center
Raleigh, NC 27699-2001
(13) This the day of 20 .
(14) Your signature:
When you have completed this form, you MUST mail or deliver the
ORIGINAL to the Office of Administrative Hearings, 1711 New Hope
Church Road, Raleigh NC 27609.
INSTRUCTIONS FOR FORM H-06B (child support-tax intercept)
“PETITION FOR A CONTESTED CASE” AND “CERTIFICATE OF SERVICE”
PLEASE PRINT CLEARLY OR TYPE
FILL IN BLANKS:
Fill in your county of residence on line (1), print your name on line
(2), and the date you received your notice of tax intercept on line
(3). Check all of the items that apply in section (4), and briefly
state the facts about your case on line (5). Check all of the items
that apply in section (6), and print your IV-D and MPI number on line
(7). Print the date on line (8), your telephone number on line (9),
your full mailing and e-mail address on line (10), Print your name on
line (11), and sign your name on line (12).
CERTIFICATE OF SERVICE:
You must mail or deliver a copy of your completed petition to the N.C.
Department of Human Resources (the address is already printed on the
petition form) and complete the “certificate of service” section on
your petition. Enter the date on line (13) and sign your name on line
(14).
FILING YOUR PETITION WITH THE OFFICE OF ADMINISTRATIVE HEARINGS:
Your contested case will commence as soon as you file your completed
original petition, properly signed, with the Office of Administrative
Hearings. Below is the mailing and physical address:
Office of Administrative Hearings
1711 New Hope Church Road
Raleigh, NC 27609
If you mail this form, the case commences when it is received and
filed in this office.
You may file your petition by fax during normal business hours by
faxing the petition to the Clerk's Office at 984-236-1871.
You may file your petition by electronic mail by an attached file
either in PDF format or a document that is compatible with or
convertible to the most recent version of Word for Windows by sending
the electronic transmission to [email protected] Electronic mail
without attached file shall not constitute a valid filing.
H-06B Instructions (06/21)