Neb. Admin. Code EDUCATION, DEPARTMENT OF, tit. 92, ch. 89, app A
BEFORE THE STATE BOARD OF EDUCATION STATE OF NEBRASKA
__________________________________)
(School district or Educational Service Unit) CASE NO. (LEAVE BLANK)
Name)
)
__________________________________)
(Address))
__________________________________,)
)
Petitioner,)
)
PETITION - in RE: denial of distance education equipment reimbursements or requirement to repay reimbursements
Petitioner, in accordance with 79-1336 R.R.S. and Title 92, Chapter 89, of the Nebraska Administrative Code, states and alleges as follows:
1. (Concisely set forth all material facts upon which the appeal is based).
2. (Attach as exhibits copies of any documents discussed above. You must attach a) a copy of the Department's denial notice or notice of reimbursement required, as applicable; b) your application for reimbursement that is the subject of the denial or repayment decision).
WHEREFORE, Petitioner requests that the State Board of Education (state remedy sought).
Dated this day of ________, 2___.
_____________________________________
(Signature)
(If attorney for petitioner, list address)
___________________________________
(Title)
VERIFICATION
State of Nebraska)
) ss
County of)
I,______________________, being first duly sworn under oath, state that I have read the contents of the foregoing petition and that to the best of my knowledge, information, and belief such contents are true and there is reasonable cause for filing said petition.
Subscribed and sworn before me this ________ day of ____________, 2____, by
(Name of Petitioner) .
(Seal) ________________________________
Notary Public
Certificate of Service
I hereby certify that this Petition, including a copy of any exhibits cited therein, were mailed to the State Department of Education by regular first class mail, postage pre-paid, or sent via facsimile to 402-471-6631 (Circle method used.) on this _____ day of ___________,
2 _____ .
__________________
Signature of Petitioner
Neb. Admin. Code EDUCATION, DEPARTMENT OF, tit. 92, ch. 89, app A