WORKERS' COMPENSATION COMMISSION COVER SHEET FOR ACTION ON CLAIMS ON APPEAL Instructions: This form must be accompanied by a copy of the Appellate Court's signed Judge's Memorandum and Order. If a hearing is required, you must also file Issues Form H24 for the matter to be put in line. To: Appeals Division Is this a claim remanded from the Circuit Court? Claimant's Name: WCC Claim #: County: Name of Presiding Judge: Name of Filing Party: COURT OF SPECIAL APPEALS Yes Date: Yes No No ACTION TAKEN:(A signed copy of the Judge's Memorandum and Order must be attached.) AFFIRM REVERSED WITHDRAWN REMAND MODIFY Remarks: DISMISSED ATTORNEY FEE PETITION (must be attached) Remarks: Submitted by: Printed Name Signature Telephone Number 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC H-11-AOA 06/2014 . American LegalNet, Inc. www.FormsWorkFlow.com