General Assistance Appeal
Verify Decision
Notice of Decision Number
Applicant Number
You can locate your Notice of Decision Number and Applicant Number on your Notice of Decision.
Appeal Decision
Name
Address
Phone
Any format that has 10 digits is acceptable. Ex. 5155551234 or (515) 555-1234
Email Address
Appealed Services
I hereby appeal the decision made regarding my application for below services and request a review of my case
Description and date of Polk County General Assistance decision
Reason(s) I believe the decision was in error
Drag and drop files here or click
Clear
Signature
By checking this box, you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.
Submit
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