CERTIFICATE OF FILING AND MAILING
I ___________________________, do hereby certify that on this _____ day of
_________, 20_____, I did cause to be filed with the Workers' Compensation Court, a correct
copy of the Petition for Review with attachment(s), and also mailed a copy with attachment(s) to
each party to the proceeding or his counsel of record as follows:
[Names and addresses of all parties or counsel of record]