| 1 Colorado Court of Appeals 2 East 14th Avenue Denver, CO 80203 Appeal from: Industrial Claim Appeals Office (ICAO) Docket/Case Number: Petitioner: , v. Respondents: Industrial Claim Appeals Office, and Filing Party Name: Street Address: City: State: Zip: Phone: E-Mail: !FOR COURT USE ! Court of Appeals Case Number: Notice of Appeal I.Final Order on Appeal I am appealing the Industrial Claim Appeals Office final order which was mailed on (date) . JDF 663 - Notice of Appeal (ICAO) Last Revised: 4, 2017 American LegalNet, Inc. www.FormsWorkFlow.com | 2 JDF 663 - Notice of Appeal (ICAO) Last Revised: 4, 2017 II.Case BackgroundIn one page or less, give the court a brief description of this case and why you are appealing: American LegalNet, Inc. www.FormsWorkFlow.com | 3 JDF 663 - Notice of Appeal (ICAO)Last Revised: 4, 2017 III.Advisory Issues on AppealList the questions you want the Court of Appeals to decide. These are often called the Issues on Appeal. IV.Lawyer or Party Information1.The lawyer for the ICAO is the Colorado Attorney GeneralRalph L Carr Colorado Judicial Center1300 Broadway, 6th FloorDenver, Colorado 80203720-528-60002.Claimant name: The claimant { does}, or { does not} have an attorney.Attorney contact information (or claimant325s if no attorney):Name of attorney (if any): Registration number (if any): Street address: City: State: Zip: Phone number: E-Mail address: !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! American LegalNet, Inc. www.FormsWorkFlow.com | 4 JDF 663 - Notice of Appeal (ICAO) Last Revised: , 2017 3.Employer name: The employer { does}, or { does not} have an attorney.Attorney contact information (or employer325s if no attorney):Name of attorney (if any): Registration number (if any): Street address: City: State: Zip: Phone number: E-Mail address: !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!4.Any Other Party325s name (if any): Check here if this party325s attorney is the same as the employer325s. Attorney contact information (if different from employer325s attorney): Name: Registration number: Street Address: City: State: Zip: Phone number: E-Mail address: !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!V.Attachments1.The ICAO final order, including the 322Certificate of Mailing323 page.Dated: Respectfully submitted, Signature: Print Name: American LegalNet, Inc. www.FormsWorkFlow.com | 5 JDF 663 - Notice of Appeal (ICAO) Last Revised: , 2017 Certificate of Service I certify that on (date) , I { mailed}, or { hand delivered} this Notice of Appeal to the Court of Appeals and mailed copies to the people listed below: (You must send a copy to each party. If a party has a lawyer, send the copy to the lawyer) (Unemployment Benefits Cases Only) Division of Unemployment Insurance 251 East 12th Avenue Denver, CO 80203-2202 Industrial Claim Appeals Office 633 17th St., Suite 00 Denver, CO 80202-3660 Colorado Attorney General 1300 Broadway, 6th Floor Denver, Colorado 80203 Respondent (For example, the employer if you are the claimant, or claimant if you are the employer): Name of Person Served: Street Address: City: State: Zip: Space for other parties served: Signature: Print Name: " American LegalNet, Inc. www.FormsWorkFlow.com