NOTICE OF APPEAL FROM REFEREE’S DECISION
In the matter of (name of the appellant), (address), (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 petitioner alleges that a fault in decision has been made on the part of the referee and is appealing said decision on the below mentioned grounds: (grounds for appeal)
Date: ____________________
___________________________
(Signature)