ADMINISTRATIVE APPEAL UNDER GENERAL STATUTES SECTION 4-183 -- NOTICE OF FILING (For use when service is made by certified or registered mail) JD-CV-137 Rev. 10-15 C.G.S. § 4-183; P.B. § 14-7A STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions to Person Appealing Decision: 1. Serve, in accordance with applicable law, a copy of the Appeal and this Notice of Filing by certified or registered mail on the agency that made the decision that is being appealed at the address of the agency or, if allowed by law, at the Office of the Attorney General, 55 Elm Street, Hartford, Connecticut. 2. Also serve a copy of the Appeal and this Notice of Filing by certified or registered mail on each party named in the decision of the agency at the address of the party contained in the decision. Name of case (Plaintiff v. Defendant) Judicial District Address of Court 3. File the Appeal and this Notice of Filing with the Clerk of the Superior Court for the Judicial District of New Britain or for the Judicial District in which the person appealing resides or, if that person is not a resident of this state, with the Clerk of the Judicial District of New Britain. Case type code (See reverse for codes) Telephone number of Court (with area code) Major: Minor: Number of Plaintiffs: Parties First Plaintiff Additional Plaintiff First Defendant Additional Defendant Additional Defendant Additional Defendant Name: Address: Name: Address: Name: Address: Name: Address: Name: Address: Name: Address: Number of Defendants: Form JD-CV-2 attached for additional parties Name (Last, First, Middle Initial) and Address of Each party (Number; Street; P.O. Box; Town; State; Zip; Country, if not USA) P-01 P-02 D-01 D-02 D-03 D-04 Notice To Defendant 1. The Plaintiff will file the attached Appeal of a final administrative decision. The Appeal attached to these papers states the claims that each Plaintiff is making. 2. To be notified of further proceedings, you or your attorney must file a form called an "Appearance" with the clerk of the above-named Court at the above Court address within thirty (30) days of the mailing of the Appeal. You do not have to come to court on that date unless you receive a separate notice telling you to come to court. 3. If you do not file an "Appearance" in a timely manner, the Court is authorized to enter a sanction against you. 4. The "Appearance" form may be obtained at the Court address above or at www.jud.ct.gov under "Court Forms." 5. If you have questions about the Notice of Filing and the Appeal, you should talk to an attorney quickly. The Clerk of Court is not allowed to give advice on legal questions. Signed (Sign and "x" proper box) * Plaintiff * Attorney for Plaintiff Name of person signing at left Date For Court Use Only File Date The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. ADA NOTICE Docket number American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CONNECTICUT JUDICIAL BRANCH CASE TYPE CODES October, 2015 MAJOR DESCRIPTION Appeals from Administrative Boards Codes Major/ Minor MINOR DESCRIPTION Zoning Taxation Liquor Motor Vehicle Commissioner Unemployment Worker's Compensation Labor Relations Board Environmental Protection Commissioner - State Commission on Hospitals/Healthcare Employees Review Board Social Services Commission Freedom of Information Commission Inland Wetlands & Conservation Commission - Local Retirement Commission Housing and Building Code Enforcement Human Rights and Opportunities Commission Department of Children and Families All other A 00 A 10 A 20 A 30 A 40 A 50 A 60 A 61 A 62 A 63 A 64 A 65 A 66 A 67 A 68 A 69 A 70 A 90 American LegalNet, Inc. www.FormsWorkFlow.com