ESA APPEAL FORM

Please input appeal information within the highlighted sections. Email this completed appeal form and a copy of the ADE Administrative Decision to esafeedback@azsbe.az.gov.

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Date: Insert Here

Account Holder Full Name: Insert Here
Pupil Initials: X.X.
Mailing Address: Insert Here
Phone Number: Insert Here
Email: Insert Here

Arizona State Board of Education
Attn: ESA Appeal
1700 West Washington Street
Executive Tower, Suite 300
Phoenix, AZ 85007  
esafeedback@azsbe.az.gov 

Pursuant to Arizona Revised Statute (A.R.S.) § 15-2403(D) and Arizona Administrative Code (A.A.C.) R7-2-1511, I request an appeal to the administrative decision made by the Arizona Department of Education (ADE). 

My request for an appeal with the Arizona State Board of Education (SBE) is consistent with A.R.S. § 15-2403(D). 

The action being appealed is:

__	Eligibility Denied
__	Contract Terminated
__	Expense Item(s) Disallowed
__	Other. {If selected, use this space to communicate what “other” ADE Decision was received}  


I am appealing ADE’s administrative decision for the following reasons:
{Use this space to provide your narrative}








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THIS SECTION IS ONLY APPLICABLE TO TERMINATED/SUSPENDED ESA ACCOUNTS

(You may delete this section if it does not pertain to your appeal)

Requested Stay
Pursuant to Arizona Administrative Code (A.A.C.) R7-2-1511(B), I am requesting a stay (“Stay Request”) so that I may continue to access ESA funds, pending the resolution of my appeal. 

My Stay Request is being submitted to the State Board of Education based on the following:
{Use this space to provide your concise statement for the Stay Request and address all matters alleged in ADE’s administrative decision}






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I attest that the information I have provided is correct.

Signed, 



{Account Holder Signature}