This graphic is a scanned image of the Form 14630, e-file Sanction Request from SBSE Lead Development Center. The next section contains the following information. Level of infraction a line, directly across is Written reprimand check box, then 1-year suspension check box, then 2-year suspension check box and Expulsion check box. Under Level of infraction is the statement If 2-year suspension or expulsion is it immediate on the same line but under Expulsion is a Yes check box, No check box. Next line under If 2-year suspension is Total number of pages box in parentheses is include this sheet and court document. Directly across is Date faxed to ANSC box. Next line under Total number of pages is EFIN(s) box. Directly across is EFIN(s) box, then the Business name box and then Location Box. Next line under the EFIN(s) box is the SSN box, then Individual’s name box, then SSN box, then Individual’s name.Next line under the SSN box, is the SSN box, then Individual’s name box, then SSN box, then Individual’s name.Next line under the SSN box, is LDC Original name box, then SEID box, Then LDC Originator’s telephone number box, then LDC Original’s e-Fax number box Next line under the LDC Original name box is the Explanation for letter box blank spaceNext line under the Explanation for letter box is Take appropriate sanctioning action using the reason(s) checked belowCheck box 5 Conduct of disreputable nature Check box 9 Unethical practices in return prepCheck box 32 Other The next section begins with the statement The Following Must be Completed by the LDC if Administrative Review RequestedUnder the statement The Following Must be Completed by the LDC if Administrative Review Requested is Does the LDC uphold its original recommended sanction straight across is Yes check box No check boxNext line under the Does the LDC uphold its original recommended sanction is, If No, explain the change and provide language to be included in the letter(s) to the provider blank space.Next line under the If No, explain the change and provide language to be included in the letter(s) to the provider is Date return to ANSPC box, then Signature boxThe next section begins with the statement The Following Must be Completed by the LDC if Review by Appeals RequestedUnder the statement The Following Must be Completed by the LDC if Review by Appeals Requested is Does the LDC uphold its original recommended sanction straight across is Yes check box No check boxNext line under the Does the LDC uphold its original recommended sanction is, If No, explain the change and provide language to be included in the letter(s) to the provider blank spaceNext line under the If No, explain the change and provide language to be included in the letter(s) to the provider is Date return to ANSPC box, then Signature box