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PROCEDURAL SAFEGUARDS NOTICE

Part B

DUE PROCESS COMPLAINT NOTICE

Today’s Date:

Requested by:

Parent

LEA

Name of Person Completing this Notice:

Relationship to Student:

Phone:

It is your responsibility to notify the opposing party of your request for due process by sending to them a copy of this Due Process Complaint Notice at the same time it is filed with the Office for Dispute Resolution.

Has the opposing party been provided a copy of this request?

Yes

No

If you require special accommodations to participate in the due process hearing, you must contact the LEA with your special needs.

Student Information

Last Name:

First Name:

Date of Birth:

Gender:

M

F

Exceptionality(ies):

LEA (Local Education Agency):

School Building Student Attends:

Parent(s) Residing with Student

Last Name:

First Name:

Relationship:

Mother

Father

Guardian

Home Phone:

Cell Phone:

Work Phone:

Fax:

Email:

Last Name:

First Name:

Relationship:

Mother

Father

Guardian

Home Phone:

Cell Phone:

Work Phone:

Fax:

Email:

Parent/Student Address:

Parent Attorney:

Attorney Phone:

Attorney Email:

Address:

Attorney Fax:

Parent Not Residing with Student

Last Name:

First Name:

Relationship:

Mother

Father

Guardian

Home Phone:

Cell Phone:

Work Phone:

Fax:

Email:

Last Name:

First Name:

Relationship:

Mother

Father

Guardian

Home Phone:

Cell Phone:

Work Phone:

Fax:

Email:

Parent/Student Address:

29July 2008 Revisions

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