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Petition For Hearing (Occupational Disease) - Workers' Compensation Court Of The State Of Montana Page 2

___ b.

The mediation procedure set forth in the Workers' Compensation Act has

been complied with.

(For injuries occurring on or after July 1, 1987.)

*6.

The following is a list of individuals who are potential witnesses for petitioner in this

matter:

Name and Address

General Subject Matter of Testimony

* 7.

The following is a list of written documents relating to this case which may be

introduced as evidence by petitioner:

WHEREFORE, petitioner respectfully prays that this petition be set for hearing and that the

following relief be granted.

(Explain what you want the Court to decide.)

1) ____________________________________________________________________

2) ____________________________________________________________________

3) _____________________________________________________________________

DATED this _____ day of _________________, 200__.

_______________________________________

Petitioner

* If additional space is needed, please attach sheet to this

PETITION FOR HEARING

Petition for Hearing (Occupational Disease) - Page 2

WCC (3/00)

Petition For Hearing (Occupational Disease) - Workers' Compensation Court Of The State Of Montana Page 2