Public Health Late Penalty Waiver Request Form
Submit your request to waive a late penalty related to a public health obligation and provide supporting details.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Public Health Obligation Reference (e.g., invoice number, case reference, or program name)
*
Briefly describe the late penalty you are requesting to be waived
*
Reason for requesting the waiver
*
Upload supporting documents (optional)
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