Notice of Appeal

NOTICE OF APPEAL

In the matter of

(name of appellant)

(address)

APPEAL FROM REFEREE'S DECISION
(number) (date)
Notice is hereby given that a decision was reached in the

above referenced matter on the above date in the City of

, State of , a copy of which is

attached hereto and sets forth the particulars in this

matter.
That appellant alleges that an error in decision has been

made on the part of the referee and is appealing said

decision on the following grounds: (grounds for appeal)
Date: ____________________

___________________________

(Signature)