Montana > Workers Compensation
Notice Of Appeal - Montana
| Notice Of Appeal Form. This is a Montana form and can be used in Workers Compensation . |
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Name ____________ ____________________ Address ______________________________ ____________________ ________________ _ Phone Number: __________________ ______ IN THE WORKERS COMPENSATION COURT OF THE STATE OF MONTANA WCC No. ____________ ________________________ ____________ Appellant vs. ________________________ _____________ Respondent. NOTICE OF APPEAL As set forth in ARM 24.5.350 appellant alleges: 1. I am appealing from the decision issued by the Department of Labor and Industry on _____________, 200_ . *2. I believe that I am entitled to the following relief: ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _*3. I believe that I am entitled to said relief on the following grounds: ________________________ ____________________ _______________________________ _ <<<<<<<<<********>>>>>>>>>>>>> 2 ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _ ________________________ ____________________ _______________________________ _*If additional space is needed, please attach sheet to this Notice of Appeal. DATED this _______ day of __________________, 200_ . ________________________ Appellant CERTIFICATE OF SERVICE I hereby certify that I served a copy of the foregoing upon the persons whose names appear below. (Use this space for name of opposing counsel and address) __________________________________________________ __________________________________________________ __________________________________________________ (Use this space for the Department of Labor and Industry, Legal Services Division and address) __________________________________________________ __________________________________________________ __________________________________________________ DATED this ______day of ______________ ___, 200__ . _____________________ _ Appellant
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