Child Placement Review Board



Assist Appeal Form


Contact Information

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Who Should Be Informed Regarding this Appeal

Please submit the names and contact information for the people who have information or should be involved in this appeal process, such as a foster parent or other people who support you. Contact information for any other individuals may be submitted by e-mail to Amy.Wilburn@state.de.us.

Independent Living Worker:
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Other:
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Other:
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Cause for Ineligibility

     

Reason for Appeal

Describe what occurred that resulted in the loss of your ASSIST stipend


Desired Outcome

What would you like the outcome of this appeal to be?


Preferred Appeal Location

              

Agreement and Signature

*Please note: By submitting this application, you are affirming that the facts set forth in it are true and complete. Your email above will serve as your signature.

Our Policy: The CPRB will review your circumstances and schedule your hearing promptly. Notification of your hearing date will be sent to you through the contact information you have provided. You will be notified of the outcome of your appeal in the same manner. If you have any questions, you may contact us at 302-577-8750.