IN THE WORKERS= COMPENSATION COURT OF THE STATE OF MONTANA __________________________________ Petitioner vs. INDEPENDENT CONTRACTOR CENTRAL UNIT Respondent. ) ) ) ) ) ) ) ) ) ) WCC No. PETITION DISPUTING ICCU REVOCATION OF INDEPENDENT CONTRACTOR EXEMPTION CERTIFICATE 1. On ____________________________, I received an independent contractor exemption certificate. A copy of the certificate is attached. 2. My exemption was revoked on _______________________________. A copy of the revocation notice is attached. 3. The mediation process before the Department of Labor and Industry has been completed. ' 39-71-415, MCA. 4. The following is a list of individuals who I may call as witnesses in this matter: Name and Address General Subject Matter of Testimony 5. The following is a list of written documents relating to this case which I may introduce as evidence: American LegalNet, Inc. www.FormsWorkFlow.com 6. I am appealing the revocation and request the Workers' Compensation Court to determine that I am an independent contractor entitled to an independent contractor exemption. DATED this day of , 20__. Petitioner=s Signature Please print or type: Name: Mailing Address: City, State, Zip: Telephone #: E-Mail Address: ____ _____________________________________ Attach copies of application for Independent Contractor Exemption Certificate and revocation notice. American LegalNet, Inc. www.FormsWorkFlow.com