NOTICE OF INTENT TO APPEAL STATE OF MAINE WORKERS' COMPENSATION BOARD APPELLATE DIVISION 27 STATE HOUSE STATION AUGUSTA, MAINE 04333 CASE NAME: WCB FILE# or AIU CASE#: ISSUANCE DATE OF DECISION: MAIL DATE OF DECISION: APPELL ANT: APPELLEE : CNOTICE A party in interest may file with the Appellate Division a notice of appeal of a decision by an A SIGNATURE OF APPELLANT 1. Mail original notice to the clerk of the Appellate Division at the above address by regular mail, or hand deliver to any regional Board office. 2. Mail one (1) copy to each other party named above. 3 . Keep one (1) copy for yourself. DATED: MONTH DAY YEAR CHECK ONE : APPELLANT HAS ORDERED TRANSCRIPT FROM (please notify Appellate Division when you receive transcript) TRANSCRIPT HAS ALREADY BEEN PREPARED REQUEST HAS BEEN MADE TO REGIONAL OFFICE TO ORDER TRANSCRIPT American LegalNet, Inc. www.FormsWorkFlow.com