Mediation Only Request Form

Office of Administrative Hearings OAH Form 63; Revised July 2012Special Education Unit Page 4 of 4STATEMENT OF SERVICEINSTRUCTIONS: Federal and state law require you to send or deliver a copy of thisRequest to each of the named parties. Additionally, you must send or deliver a copy tothe Office of Administrative Hearings. Retain a copy for yourself. Please indicate yourcompliance with this requirement by checking the appropriate box, signing and datingbelow.I have provided a copy of this Request for Mediation Only to all the named partiesand to the Office of Administrative Hearings by:☐☐☐☐First Class MailFacsimile TransmissionMessenger Service (UPS, FedEx, Other courier service) Please attach proofof servicePersonal Delivery (If other than requestor please nameperson who made service)___________________________________Signature of person completing thisStatement of Service________________________Date of service