FORM 116A. PETITION FOR WRIT OF CERTIORARI STATE OF MINNESOTA IN SUPREME COURT CASE TITLE: Employee Taxpayer, PETITION FOR WRIT OF CERTIORARI APPELLATE COURT CASE NUMBER: [TO BE ADDED BY CLERK] vs. Employer Insurer Commissioner of Revenue. WORKERS' COMPENSATION COURT OF APPEALS [OR TAX COURT] NUMBER: DATE OF SERVICE OF WRITTEN NOTICE OF DECISION: [DATE OF FILING OF TAX COURT DECISION] TO: The Supreme Court of the State of Minnesota: The above-named relator hereby petitions the Supreme Court for a Writ of Certiorari to review a decision of the Workers' Compensation Court of Appeals [Tax Court], upon the grounds that it is not in conformity with the terms of the Workers' Compensation Act and is unwarranted by the evidence [The Tax Court was without jurisdiction, the Order of the Tax Court was not justified by the evidence, or the Tax Court committed an error of law]. DATED: NAME OF [RELATOR] AND ATTORNEY (IF APPLICABLE), ADDRESS (INCLUDING ZIP CODE), TELEPHONE NUMBER, EMAIL ADDRESS (IF AVAILABLE) SIGNATURE [OF RELATOR, OR ATTORNEY IF REPRESENTED] (The procedure for obtaining a writ of certiorari from the Supreme Court to review decisions of the Workers Compensation Court of Appeals or the Tax Court is set forth in RCAP 116. The rule prescribes the subject matter of writs in the Supreme Court, contents of the petition, bond or security, filing and fees, and requirements for service. A completed statement of the case must accompany the petition.) American LegalNet, Inc. www.FormsWorkFlow.com