Notice Of Appeal

______

Attorney at Law

IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA

WCC No.

Petitioner

vs.

Respondent/Insurer.

_____________________________________________________________________

NOTICE OF APPEAL

¶ 1

NOTICE IS HEREBY GIVEN that the Petitioner __________ appeals to the

Supreme Court of the State of Montana from the FINDINGS OF FACT, CONCLUSIONS

OF LAW AND ORDER, entered into this action on _________________, 200__.

¶ 2

This matter is subject to mediation under Rule 54, Mont. R. App. P.

DATED this _____ day of ______________, 200__.

By:__________________________________

Attorneys for ______________________

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