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File for an Appeal Online

Appeal Form
Date of Appeal:
Full Name: *
Street Address or
P.O. Box:
City:
State:
Zip:
E-Mail Address: *
Daytime Phone Number:
What are you appealing?
Appeal Description:
(In plain language and detail,
include sufficient facts and
reasons upon which your appeal
is based.)

Note: To expedite your appeal, include any correspondence you
may have received concerning the denial that you are appealing.
To help us serve you better, please provide your e-mail address.

* Required Field


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LA County Home
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LA County Code

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