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Fair Hearing Request Form

Office of Administrative Hearings
P.O. BOX 1930
Albany, NY 12201-1930
Fax:(518) 473-6735

Note: For security purposes, you have 15 minutes to complete this form, otherwise your request will not be received and you will need
to start over.

* Indicates Required Information. Correct and complete information will permit us to promptly process your request.

Case Information
(If fair hearing is for someone other than the case name, describe who it is for in the comments box below.)

Belliard
* Last Name:

Farailda
* First Name:

Middle Initial:

* Street Address: 2680 Frederick Douglass Blvd

8C
Suite/Floor/Apt#:

* City: New York

* State: NY

Zip Code: 10030

Email Address: belliardadmins@gmail.com

Phone (include area code, no dashes): 3476920144

Date of Birth (mm/dd/yyyy): 09/24/1976

SSN (numbers only, no dashes): 055604752

Gender (click one): Male Female

Case #: 00006318375A

Client ID Number (CIN): ZK86327W

How many adults in case? 2

How many children in case? 2

* Upstate County or NYC Center #: East End Center

If an interpreter is needed, please select the language or
English
dialect:
If other language, enter the language or dialect:

Is client homebound? Yes No

(If yes, please explain the client’s reason for being homebound in the Comments box below, and mail medical documentation to the
above address. Do not delay submitting this fair hearing request form to obtain medical documentation.)

RESTRICTIONS
Mark the days or times you or your representative cannot participate in a hearing and explain in the comment box below. We will not
restrict the scheduling of the hearing unless an explaination is provided.
Monday Tuesday Wednesday Thursday Friday
Morning
Afternoon

Representative/Requestor Information
(If there is a representative or you are NOT the person listed above.)
Name: Farailda Belliard

Representative Organization:

Street Address: 2680 Frederick Douglass Blvd

8C
Suite/Floor/Apt#:

City: New York

State: NY

Zip Code: 10030

Phone (include area code, no dashes): 3476920144 Extension (limit 5 numbers) :

Email Address: belliardadmins@gmail.com

Enter comments to clarify information on this page including the reason for being homebound, additional mailing addresses,
phone numbers and extensions, reason for restrictions, etc. Later, you will have an opportunity to describe the reason you
are asking for a fair hearing.
Noelani Pilgrim’s Does not want to Comply with the requirements for me to comply with the
requirements for me to keep this account open. I don’t know what to do at this point.

Number of characters remaining for your description : 500 Comments contain at most 500 characters, only letters, numbers, and
regular punctuation marks. Multiple dashes or apostrophes are not allowed

Enter the name of person filling out this form

Farailda Belliard

* You must choose "My request is about a notice" or "My request is not about a notice" in order to continue.

My request IS about a notice My request IS NOT about a notice

You may add more issues later.

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