FORM 115B. WRIT OF CERTIORARI STATE OF MINNESOTA IN COURT OF APPEALS CASE TITLE: WRIT OF CERTIORARI Relator, vs. Respondent, (AGENCY OR BODY) NUMBER: (Agency or Body), Respondent. TO: (Agency or Body) You are hereby ordered to return to the Court of Appeals and serve on all parties in accordance with Rule 115.04, subdivision 3, within 30 days after service of the petition or 14 days after delivery of a transcript, whichever is later, an itemized statement of the record, exhibits and proceedings in the above-entitled matter so that this court may review the decision of the (agency or body) issued on the date noted above. You are further directed to retain the actual record, exhibits, and transcript of proceedings (if any) until requested by the clerk of the appellate courts to deliver them in accordance with Rule 115.04, subdivision 5. Copies of this writ and accompanying petition shall be served forthwith either personally or by mail upon the respondent (agency or body) and upon the respondent or its attorney at: ___________________________ ___________________________ (address) Proof of service of the writ and of the itemized statement shall be filed with the clerk of the appellate courts. DATED: Clerk of Appellate Courts (Clerk's File Stamp) By: ____________________ Assistant Clerk COURT OF APPEALS NUMBER: DATE OF DECISION: American LegalNet, Inc. www.FormsWorkFlow.com