STATE OF COLORADO OFFICEthOF ADMINISTRATIVE COURTS 633 17 Street, Suite 1300, Denver, CO 80203 Fax: (303) 866-5909 1259 Lake Plaza Drive, Suite 210, Colo. Springs, CO 80906 Fax: (719) 576-5978 th 222 S. 6 Street, Suite 414, Grand Jct., CO 81501 Fax: (970) 248-7341 Claimant, COURT USE ONLY vs. WC NUMBER: Employer, and Respondent. PETITION TO REVIEW AND REQUEST FOR TRANSCRIPT (RULE 26 OACRP) TO THE OFFICE OF ADMINISTRATIVE COURTS AND JUDGE _________________ : The ( claimant/ employer/ insurance carrier) petitions for review of the order of Judge _______________________ issued on _________________ (mo/day/yr). Petitioner objects to the Findings of Fact, Conclusions of Law, and Order of the Judge on the following ground(s): (Set forth in detail the particular alleged errors and your objections to the order. You may attach additional pages): American LegalNet, Inc. www.FormsWorkflow.com The Petitioner request that a transcript(s) of the hearing be prepared and included as part of the record for the Petition to Review. Rule 26(D) OACRP. If requesting a partial transcript, also indicate the approximate ending time and description. Date(s) of Hearing(s): Room and time the hearing began: The Petitioner requests that the Office of Administrative Courts transmit the audio recording of the hearing to the following for preparation of the transcript. CHECK ONE of the following: (Note: The firms listed have indicated a willingness to prepare transcripts at the per page rate set by the Colorado Supreme Court. The listing of a firm is not an endorsement by the Office of Administrative Courts) A/V Tronics, Inc., 600 17th Street, Suite 2800, Denver, CO 80202: (303) 634-2295; Agren Blando Court Reporting & Video, Inc., 216 16th Street, Suite 650, Denver, CO 80202: (303)296-0017 Federal Reporting Service, 17454 E. Asbury Place, Aurora, CO 80013: (303) 751-2777; Other court reporter or transcriptionist who does not have an interest in the case: Name and Mailing Address: Phone Number: The Petitioner is indigent and has filed a Form #WC35, Application for Indigent Determination (Transcript), with the Division of Workers’ Compensation. American LegalNet, Inc. www.FormsWorkflow.com Certificate of Mailing / Service I certify that true and correct copies of the foregoing Petition To Review And Request For Transcript were either deposited in the U.S. Mail, postage prepaid, or delivered, addressed as follows: Signature Date Mailed REV 05/06 American LegalNet, Inc. www.FormsWorkflow.com