Approved, SCAO Original - Circuit court 1st copy - District court/agency 2nd copy - Appellee 3rd copy - Appellant STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Court address CASE NO. APPLICATION FOR LEAVE TO APPEAL Court telephone no. Plaintiff's name, address, and telephone no. Appellant Appellee v Defendant's name, address, and telephone no. Appellant Appellee Plaintiff's attorney, bar no., address, and telephone no. Defendant's attorney, bar no., address, and telephone no. 1. I, Name , request leave to appeal a judgment/order/decision entered on in the Court name and number or agency Date by Name of judge . Bar no. The nature of the judgment/order/decision being appealed is 2. No appeal of right exists. The time for taking an appeal under MCR 7.105(A) has expired. An appeal of right exists, but waiting to appeal of right would not be an adequate remedy. . 3. This application for leave is being filed a. within the time required by MCR 7.105(A). b. after, but not more than 6 months after, entry of the judgment/order/decision appealed pursuant to MCR 7.105(A). (If the application is filed under 3.b, a statement of facts explaining the delay must be attached.) c. because an appeal of right from an agency's order or decision was not timely filed and statute authorizes a late appeal. 4. I allege the following errors. (Attach additional pages as needed.) 5. I request the following relief. (Attach additional pages as needed.) 6. The following is my position supporting each issue, as required by MCR 7.212(C). (Attach additional pages as needed.) 7. This is an interlocutory appeal. I will suffer substantial harm by awaiting final judgment before taking an appeal because: (Attach additional pages as needed.) Date Appellant signature CERTIFICATE OF MAILING I certify that on this date I served a copy of this application for leave to appeal on the parties or their attorneys and on the trial court or agency by first-class mail addressed to their last-known addresses as defined by MCR 2.107(C)(3). Date CC 298 (6/12) Signature APPLICATION FOR LEAVE TO APPEAL MCR 7.103(B), MCR 7.105 American LegalNet, Inc. www.FormsWorkFlow.com