Ala. Admin. Code r. 660-1-3-A
APPENDIX A - CHAPTER 660-1-3 FORMS
ALABAMA DEPARTMENT OF HUMAN RESOURCES
PETITION FOR A RULE CHANGE
1. This is a petition:
[ ] To adopt a new rule
[ ] To modify an existing rule
[ ] To repeal an existing rule
2. This Petition is presented by (Petitioner):
Name: ______________________________________________
Address: ___________________________________________
___________________________________________
___________________________________________
Phone: ___________________________________________
3. The person signing the petition is:
[ ] The true party in interest and is the Petitioner
[ ] An officer or employee of the Petitioner
State Title: _______________________________
[ ] The attorney of the Petitioner
[ ] Other (specify): ___________________________
____________________________________________
4. The Petitioner's representative is:
Name: ______________________________________________
Address: ___________________________________________
Phone: _____________________________________________
5. If this Petition proposes to modify or repeal an existing
rule, specify the rule:
Rule No. ___________________________________________
6. If this Petition proposes the adoption of a new rule,
specify all existing rules it would affect, and specify
what chapter of the Department Administrative Code it
should be a part of.
____________________________________________________
____________________________________________________
7. Attach a typed (double-spaced) narrative as to why the new
rule, the modification or the repeal is needed,
specifying:
(1) The persons or class of persons it would affect
and how it would affect them.
(2) The benefits and disadvantages of the proposed
rule, modification or repeal.
(3) The estimated cost or cost savings to the
Department.
(4) Any other reasons why the rule, modification or
repeal should be accepted by the Department.
(5) The legal authority for the proposed rule,
modification or change.
(6) The names and addresses of any persons,
organizations and the identity of any class of
persons who would be or could be adversely
affected by the proposed rule, modification or
repeal.
This is to be labeled "Exhibit A."
8. Attach as "Exhibit B" etc. any other documents, reports or
1. Information about Petitioner:
Name: ______________________________________________
Address: ___________________________________________
Phone: _____________________________________________
2. Information about Petitioner's Representative:
Name: ______________________________________________
Address: ___________________________________________
Phone: _____________________________________________
Title: _____________________________________________
3. Petitioner is:
[ ] Recipient (#_____________________________)
[ ] Applicant (SSAN _________________________)
[ ] Contractor/Provider (#___________________)
[ ] Other (specify) ____________________________ ____________________________________________
If you checked "Other" specify how a Department of Human Resources rule affects you and indicate what legal standing you have to request a ruling.
4. What rules or laws are involved in this report?
____________________________________________________ ____________________________________________________
5. Attach a typed (double-spaced) narrative stating the facts upon which you based this petition. Be specific. Give dates. Include a proposed resolution of the problem Chapter 660-1-3 Human Resources Supp. 12/31/92 1-3-8 presented by your petition. Label this narrative "Exhibit A. "
NOTE: The declaratory ruling will be based solely on the facts you give. If you omit a material fact or facts, the Department may not honor the ruling if you attempt to rely on it later.
6. Attach as "Exhibit B," etc., any other documents that you want to be considered in giving you a ruling.
Date this the _____________ day of ______________, 19___.
_________________________________________
Signature of Petitioner or Representative
NOTE: Send the original and five (5) copies to: Administrative Procedures Secretary, Department of Human Resources, State of Alabama, 64 North Union Street, Montgomery, Alabama 36130-1801.
APPENDIX A - CHAPTER 660-1-3 FORMS
ALABAMA DEPARTMENT OF HUMAN RESOURCES
studies that you want to be considered in connection with
your petition.
Date this the ___________day of _____________, 19___.
____________________________________
Signature of Petitioner or Representative
NOTE: The original form and five (5) copies must be submitted to: Administrative Procedures Secretary, Department of Human Resources, State of Alabama, 64 North Union Street, Montgomery, Alabama 36130-1801.
APPENDIX A - CHAPTER 660-1-3 FORMS
ALABAMA DEPARTMENT OF HUMAN RESOURCES
PETITION FOR A DECLARATORY RULING
A. APPOINTMENT OF REPRESENTATIVE
I appoint __________________________________________ (Name) __________________________________________ (Address) __________________________________________ __________________________________________ __________________________________________ (Phone)
to act as my representative in connection with:
[ ] Petition for a Rule Change
[ ] Petition for a Declaratory Ruling
I hereby authorize my representative to fully act in my stead in connection with the petition involved. This appointment shall remain in full force and effect until I notify the Department of Human Resources in writing that my representative's authority has been withdrawn.
Date _______________ Signature ___________________________ (Petitioner) Address: ____________________________ ____________________________ ____________________________ Phone: ____________________________
B. ACCEPTANCE OF APPOINTMENT
I, __________________________, hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Department of Human Resources; that I am not, as an officer or employee of the State of Alabama, disqualified or otherwise exempted by law from acting as the petitioner's representative.
My relationship to the petitioner is ______________________ (attorney, legal guardian, relative, etc.)
Date _______________ Signature ___________________________ (Representative)
Address: ____________________________ ____________________________ ____________________________
Phone: ____________________________
NOTE: The original form must be submitted to: Administrative Procedures Secretary, Department of Human Resources, State of Alabama, 64 North Union Street, Montgomery, Alabama 36130-1801.