Neb. Admin. Code EDUCATION, DEPARTMENT OF, tit. 92, ch. 89, app B
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 incentive payments
)
)
)
Petitioner, in accordance with 79-1337 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 copy of:
(a) the Department's denial notice concerning the incentive payments at issue; and
WHEREFORE, Respondent 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 answer and that to the best of my knowledge, information, and belief such contents are true.
Subscribed and sworn before me this ________ day of ________, 2__, by
(Name of Respondent) .
__________________________
(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 B