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Notice Of Appeal To Workers Compensation Court Of Appeals NO0016 - Minnesota

Notice Of Appeal To Workers Compensation Court Of Appeals Form. This is a Minnesota form and can be used in Workers Comp .
 Fillable pdf Last Modified 8/20/2008
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Mailing Address: 443 Lafayette Road North St. Paul, MN 55155 EMPLOYEE SOCIAL SECURITY NUMBER STATE OF MINNESOTA OFFICE OF ADMINISTRATIVE HEARINGS WORKERS' COMPENSATION DIVISION 100 Washington Avenue South, Suite 1700 Minneapolis, MN 55401-2139 (612) 341-7600 NO0016 DO NOT USE THIS SPACE DATE(S) OF CLAIMED INJURY EMPLOYEE VS. EMPLOYER(S) AND INSURER (S) AND Notice of Appeal to Workers' Compensation Court of Appeals Please PRINT or TYPE. Enter dates in MM/DD/YYYY format. TO THE ABOVE-NAMED PARTIES AND THEIR ATTORNEYS, PLEASE TAKE NOTICE: That the above-named party, Compensation Court of Appeals from the decision of Compensation Judge dated the day of , 20 , and the following issues are raised in this Notice of Appeal: , appeals to the Workers' Further, that the specific findings and orders appealed from are numbered in the decision as follows: (give numbers only). If there are other grounds which cannot be raised by reference to the findings, attach an explanation. (See Minn. Stat. ยง 176.421.) DATE SIGNED SIGNATURE OF PERSON FILING APPEAL PRINTED NAME AND TITLE ADDRESS CITY STATE ZIP CODE TELEPHONE IMPORTANT: The notice of appeal must be served upon each adverse party, and the original, with proof of service, filed with the Office of Administrative Hearings, together with a $25 filing fee payable to the State Treasurer/OAH. This notice must be served and the original notice and filing fee received by OAH within 30 days after notice of the Judge's decision has been served by the Office of Administrative Hearings. MN NO0016 (4/05) (over) American LegalNet, Inc. www.USCourtForms.com EMPLOYEE SOCIAL SECURITY NUMBER DATE(S) OF CLAIMED INJURY STATE OF MINNESOTA COUNTY OF } } } ss. AFFIDAVIT OF SERVICE , being first duly sworn, says that on , (s)he deposited a true and correct copy of the original NOTICE OF APPEAL TO WORKERS' COMPENSATION COURT OF APPEALS in the United States Mail in the City of , postage prepaid, duly enveloped and stamped, addressed to: (List opposing attorneys and parties not represented by an attorney with their addresses). Employee: Employee Attorney: Employer: Employer/Insurer Attorney: Insurer: Other Party (Specify): Other Party (Specify): Commissioner of Labor and Industry State of Minnesota Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155 FILED WITH: Office of Administrative Hearings Workers' Compensation Section 100 Washington Square, Suite 1700 Minneapolis, Minnesota 55401 Subscribed and sworn to before me this Notary Public My Commission expires American LegalNet, Inc. www.USCourtForms.com day of Signature
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