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)

 Notice of Appeal

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