Fillable Printable Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged
Fillable Printable Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged
Confidentiality Notice: The information contained in this facsimile may be confidential and legally privileged
FAX COVER SHEET
Hardship Request
Date:
Sender:
To:
Bill Brautigam
Office Name:
Office Name:
APD Central Office
Address:
Address:
500 Summer St NE E12
City:
City:
Salem
State:
Zip:
State:
OR
Zip:
97301
Phone No.:
Phone No.:
503.947.5204
Fax No.:
Fax No.:
503.378.7823
Total Pages:
Re:
Application for hardship waiver
Potential APS case
Confidentiality Notice: The information contained in this facsimile may be confidential and
legally privileged. It is intended only for use of the individual named. If you are not the
intended recipient, you are hereby notified that the disclosure, copying, distribution, or taking
of any action in regards to the contents of this fax – except its direct delivery to the intended
recipient – is strictly prohibited. If you have received this fax in error, please notify the sender
immediately and destroy this cover sheet along with its contents, and delete from your system,
if applicable.
DHS 2009 (REV 9/2003)
