Form A

_____________________________________________

IN THE MATTER OF THE APPEAL OF, ______________________________
                                                                                                                        (Parent's Name)
on behalf of_______________________________,
                                        (Child's Name)

                                            Petitioners,

NOTICE OF INTENTION 
TO SEEK REVIEW

                    -against-

                    _______________________________,
                            (School District's Name)
                                                 Respondent.

_____________________________________________

NOTICE:

The undersigned intends to seek review of the determination of the hearing officer concerning the identification, evaluation, program or placement of ______________________ (child's name).  Upon receipt of this notice you are required to have prepared a written transcript of the proceedings before the hearing officer in this matter.  A copy of the transcript, of each exhibit submitted at the hearing, and of the decision of the hearing officer must be filed by the _____________________________________________ (name of Board of Education) with the Office of State Review of the New York State Education Department, 80 Wolf Road, Suite 203, Albany, NY 12205-2643 within 10 days after service of this notice.

Dated: _____________________

                                                                                     ____________________________
                                                                                                    (signature)
                                                                                                                              (parent or person in parental relationship
                                                                                                        who has initiated the appeal)