Reset STATE OF MINNESOTA OFFICE OF ADMINISTRATIVE HEARINGS WORKERS222 COMPENSATION DIVISION NO0016 DO NOT USE THIS SPACE Notice of Appeal to Workers222 Compensation Court of Appeals PRINT IN INK or TYPE. Enter dates in MM/DD/YYYY format. Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers222 compensation dispute. The data will be used by the office of administrative hearings (OAH) and Workers222 Compensation Court of Appeals staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department of labor and industry222s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the workers222 compensation court of appeals; the departments of revenue and health; and the workers222 compensation reinsurance association. TO THE ABOVE-NAMED PARTIES AND THEIR ATTORNEYS, PLEASE TAKE NOTICE: That the above-named party, , appeals to the Workers222 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: 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. 247 176.421.) 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 Judge222s decision has been served by the Office of Administrative Hearings. MN NO0016 (6/18) (over) PO Box 64620 St. Paul, MN 55164-0620 (651) 361 - 7900 AND INSURER (S) AND EMPLOYER(S) VS. EMPLOYEE DATE(S) OF CLAIMED INJURY WID or SSN American LegalNet, Inc. www.FormsWorkFlow.com WID or SSN DATE(S) OF CLAIMED INJURY STATE OF MINNESOTA } } ss. PROOF OF SERVICE COUNTY OF } , being first duly sworn, says that on , (s)he deposited a true and correct copy of the original NOTICE OF APPEAL TO WORKERS222 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): COPY TO: Department of Labor and Industry PO Box 64221 St. Paul, MN 55164-0221 I declare under penalty of perjury that everything I have stated in this document is true and correct. Dated Signature Name Street Address City/State/Zip Telephone American LegalNet, Inc. www.FormsWorkFlow.com
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