Form App. R. 11-4 IN THE INDIANA [SUPREME COURT/COURT OF APPEALS/TAX COURT] CAUSE NO.________________________ _____________________, Appellant/Petitioner, ([Plaintiff/Defendant/Claimant Respondent] below), v. _____________________, Appellee/Respondent, ([Plaintiff/Defendant/Claimant Respondent] below), ) ) ) ) ) ) ) ) ) ) ) ) [Appeal or Petition] from the _________ Court or Administrative Agency Trial Court [or Administrative Agency number] Case No.:____________________ The Honorable ______________, Judge Appellate Rule 28(A)(9)(d) and Administrative Rule 9(G)(5) Notice of Exclusion of Confidential Information from Public Access (TRANSCRIPT ON APPEAL) Pursuant to Appellate Rule 28(A)(9)(d), [party name], provides this notice that the following confidential information contained in the transcript on appeal should be filed on green paper and remain excluded from public access in accordance with the authority listed below: Transcript page and line number(s). Administrative Rule 9(G) grounds upon which exclusion is authorized. [List here] [List 9(G) grounds here.] [NOTE: If 9(G)(2)(a) or (3) provides the basis for exclusion, you must also list the specific law, statute, or rule declaring the information confidential.] American LegalNet, Inc. www.FormsWorkFlow.com Respectfully submitted, _________________________ [Signature] CERTIFICATE OF SERVICE I certify that on this _______ day of _______________, 20_____, the foregoing was served upon the following by [state method of service]: [list names and addresses of counsel of record on appeal and court reporter] _________________________ [Signature] American LegalNet, Inc. www.FormsWorkFlow.com