20.C Good Cause Withdrawal Statement

Date

Customer Name

Customer Address

Case Number:

GOOD CAUSE WITHDRAWAL STATEMENT

On ____________________, Good Cause was granted for the following child(ren):

On ____________________, you are withdrawing your request for Good Cause. Future claims for Good Cause on this case will require a new request.

By withdrawing your request, cooperation with our office is now required in order to continue to receive POWER benefits.

Please contact your case worker if you have any questions or need further direction.

________________________________________

Customer Name

Cross Reference

None