CITIZENS APPEAL FORM
*LEVEL IV

(To State Superintendent of Schools)

_____________________ COUNTY SCHOOLS


*If the citizen(s) is/are not satisfied with the decision of the county board of education at Level III, that decision may be appealed to the State Superintendent of Schools, if filed within thirty days. The citizen(s) shall include with this form a statememt of basic facts related to the appeal plus copies of the appeals and decisions at all lower levels, available transcripts of hearing, and any other supportive informaiton. A copy of all information provided the State Superintendent shall, at the same time, be transmitted to the county superintendent of schools.

NOTE: An appeal cannot be heard at Level IV without an identified violation of state law or policy, rule or regulation of the State Board of Education (see Level I, INFORMATION REGARDING APPEAL).

CITIZEN(S) MAKING APPEAL

______________________________
Name		 ______________________________
Address		 ______________________________
Phone
______________________________
Name		 ______________________________
Address		 ______________________________
Phone

v.

RESPONDENT

______________________________
County Board of Education		 ______________________________
County Superintendent

At the request of either party, a hearing shall be conducted by the State Superintendent or his/her designated hearing officer.

I/we do _______ , do not __________ request a hearing before the State Superintendent of Schools or his/her designated hearing officer on this appeal.

I/we do hereby swear that the matters set forth in this appeal are true insofar as is know. I/we certify that a copy of this Level IV appeal and accompanying information has been proided the county superintendent of schools.

_____________
Date		 ____________________
Signature		 _____________
Date		 ____________________
Signature

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