IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI SMALL CLAIMS COURT ASSOCIATE CIRCUIT COURT DIVISION AT INDEPENDENCE Case No.: , (Name/Address/Phone Number) Petitioner, VS. The Sheriff of Jackson County, Missouri in His/Her Official Capacity , Respondent. APPEAL OF A DENIAL OF A CONCEALED CARRY PERMIT The denied applicant states that the Sheriff of Jackson County, Missouri, without just cause, denied his/her properly completed application for a concealed carry permit. The denied applicant affirms that all of the statements in the application are true. A copy of the Sheriff222s said written refusal, marked Exhibit 223A224, is attached to and made part hereof. Date Denied Applicant Hearing Date: at .m. Division: Floor , located at: Eastern Jackson County Courthouse 308 West Kansas Avenue Independence, MO 64050 CERTIFICATE OF DELIVERY I certify that a copy of the foregoing was mailed to the Jackson County Sheriff222s Department on the day of , 20. American LegalNet, Inc. www.FormsWorkFlow.com