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ERS 202 (August 2009) Appendix A

PETITION FOR CONTESTED CASE HEARINGSAMPLE FORMAT

BOARD OF TRUSTEESEMPLOYEES’ RETIREMENT SYSTEM

STATE OF HAWAII

)In the Matter of ) DOCKET No.:

_____________________

) (To be filled in by agency)

__________________,

)(Petitioner’s first and last name) ) PETITION FOR CONTESTED CASE

) HEARINGPetitioner, )

) Attachments or Exhibits:for a Contested Case Hearing. )

)

1.

____________________________________________

)) 2.

__________________________________

)) 3.

_________________________________

))

4.—

_____________________________________________________________________)

PETITION FOR CONTESTED CASE HEARING

PETITIONER’S INFORMATION

A. Petitioner’s Name: (Type or write in the Petitioner’s full legal name.)

B. Petitioner’s Mailing Address: (Type or write in the Petitioner’s complete mailingaddress. Unless the Petitioner is represented by an attorney, all notices andpleadings in this proceeding will be mailed to this address.)

C. Petitioner’s Telephone Number: (Type or write in the Petitioner’s completetelephone number.)

D. Petitioner’s Fax Number: (Type or write in the Petitioner’s completefax number,if available.)

E. Petitioner’s E-Mail Address: (Type or write in the Petitioner’s e-mail address, ifavailable.)

—1—

ERS 202 (August 2009) Appendix A

2. STATEMENT OF PETITIONER’S INTEREST, REASONS FOR SUBMITTINGPETITION AND ISSUES

A. Nature of Petitioner’s Interest: (Briefly state the nature ofPetitioner’s interest inthis Petition. For example: “I am a member of the Employees’ Retirement System,”or “I am a beneficiary of the Employees’ Retirement System. “)

B. Petitioner’s Reasons for Submitting Petition: (Briefly state Petitioner’s reasonsforfiling this Petition. For example, “The Employees’ Retirement System hasimproperly calculated my service credits. “)

C. Petitioner’s Statement of Issues: (Briefly describe all of the issues being raised inthis Petition including all of the claims being made under the Petition. For example,“Under Hawaii Revised Statutes 88-132, 1am claiming military service creditbecause I was an active member of the Employees’ Retirement System when I wenton military leave in March 1972. “)

3. STATEMENT OF RELEVANT FACTS(In this section of the Petition, state all of the facts that Petitioner believes are relevant tothe issues being raised in the Petition, including a chronology of events, f that would behelpful to understanding the issues. IfPetitioner is disputing a denial of retirement benefits,service credits, or some other entitlement, state the date of the denial, the date when youbecame aware of the denial, and how you discovered or learned of the denial.)

4. STATEMENT OF LEGAL REASONS SUPPORTING THE PETITION(In this section of the Petition, state the legal reasons supporting Petitioner’s claims orpositions on issues raised in the Petition. If the legal reasons include any court decisions orother legal authorities, identify them and state how they support Petitioner’s claims orpositions.)

5. PETITIONER’S POSITION ON STATUTES, RULES, AND ORDERS IN QUESTION

A. Statutes: (Idenflfy any statutes which are involved in the Petition and Petitioner’sposition on those statutes. For example, fPetitioner is disputing a denial ofretirement benefits, identfy all statutes under which Petitioner believes that thosebenefits should be granted. If Petitioner is contesting the interpretation of anystatutes by the Employees’ Retirement System (ERS), identify the statutes in questionand provide Petitioner’s interpretation of those statutes.)

B. Rules: (Identify any ERS or other agency rules which are involved in the Petition.For example, fPetitioner is claiming some right or benefit, identify all rules whichsupport Petitioner’s claim. IfPetitioner is claiming that any ERS rules are invalid,identify those rules and state the reasons that Petitioner claims they are invalid. IfPetitioner is contesting the ERS’ interpretation of any rules, identify the rules andprovide Petitioner’s interpretation of those rules. If no ERS or other agcncy rulesare involved, state “None” or “Not Applicable”.)

-2-

ERS 202 (August 2009) Appendix A

C. Orders: (Identify any courts ERS or other agency orders which Petitioner claimsare involved in the Petition. For example, ifPetitioner is claiming some right orbenefit, identify all orders which support Petitioner’s claim. IfPetitioner is claimingthat a prior ERS order is invalid identify the order, and state the reasons whyPetitioner claims it is invalid. IfPetitioner is contesting the ERS’ interpretation ofany orders, identify the orders ,and provide Petitioner’s interpretation of thoseorders. Attach a copy of each order identified to this Petition. If no orders areinvolved, state “None” or “Not Applicable”.)

6. RELIEF REQUESTED(In this section, state exactly and completely what reliefor remedy Petitioner is seeking fromthe Board of Trustees of the Employees’ Retirement System under this Petition.)

7. NAMES OF OTHER PARTIES OR POTENTIAL PARTIES(State the full names and addresses, fknown, of any persons, firms, or other entities thatPetitioner believes should be made parties to this proceeding or who are potentially partiesto this proceeding. If there are no other parties or potential parties, state “None” or “NotApplicable. “)

8. APPEARANCE ON BEHALF OF PETITIONERIf the Petitioner is being represented by an attorney or other agent in this proceeding,provide the name, mailing address, telephone number, fax number (if available), and e-mailaddress (if available) of the attorney or other agent below. By filling in this information,Petitioner is authorizing the Employees’ Retirement System to provide all notices and otherdocuments in this proceeding to the attorney or agent identified below instead of to thePetitioner.

A. Name:

B. Mailing Address:

C. Telephone Number:

D. Fax Number:

E. E-Mail Address:

This Petition is being filed pursuant to Section 91-9, Hawaii Revised Statutes, and HawaiiAdministrative Rules Chapter 6-23. 1 declare under penalty of perjury that the facts alleged in thisPetition are, to the best of my knowledge, true and correct.

DATED: (Type or write in Petitioner’s city, state, and the date the Petition is signed)

ByPetitioner (signature)

-3-