(Name, Address, Phone Number) IN THE WORKERS= COMPENSATION COURT OF THE STATE OF MONTANA , ) Appellant, ) ) WCC No. vs. ) ) NOTICE OF APPEAL , ) PURSUANT TO ) 247 39-71-610, MCA Appellee. ) As set forth in ARM 24.5.314 Appellant alleges: 1. I am appealing from the decision issued by the Department of Labor and Industry on , 20 , regarding interim benefits under 247 39-71-610, MCA. 2. I believe that I am entitled to the following relief: 3. I believe that I am entitled to said relief on the following grounds: (If additional space is needed, please attach sheet to this Notice of Appeal.) DATED this day of , 20. Appellant CERTIFICATE OF SERVICE I hereby certify that I served a copy of the foregoing Notice of Appeal upon the persons whose names appear below. American LegalNet, Inc. www.FormsWorkFlow.com (Use this space for name of opposing counsel) (Use this space for the Department of Labor and Industry, Legal Services Division) DATED this day of , 20. American LegalNet, Inc. www.FormsWorkFlow.com