INTHENEBRASKAWORKERS222COMPENSATIONCOURT OCRSuspect) Docket:Page:[employeename] OCRSuspect\ Plaintiff, OCRSuspectj vs)NOTICE)OF OCRSuspect} APPEAL[nameofemployerornameofemployerandinsurancecompany] OCRSuspectj Defendant(s).)COMESNOWthe[plaintiffordefendant(s)]andherebygivesnoticeofintenttoappealthe[AwardorOrderofDismissalorifother,titleofdecision]enteredbytheNebraskaWorkers'CompensationCourtontotheNebraskaCourtofAppeals.[dateofthedecision][signyourname][printyourfullname][printyourstreetaddress][printyourcity,state&zipcode]NOTE:Seeothersideofthisformforinstructions.[printyourtelephonenumber]Pleasekeepthecourtinformedifyouchangeyouraddressorphonenumber.CERTIFICATEOFSERVICETheundersignedherebycertifiesthatacopyoftheaboveNoticeofAppealwasservedupon:[Checkonemethodofserviceforeachpartyserved]Name:Name:Mail:[nameofservicerecipient] OCRSuspectEH Mail:[nameofservicerecipient][streetaddress][streetaddress]Fax:[city,state,&zipcode]Fax:[city,state,&zipcode]EDHandDelivery:[faxnumber,includingareacode]EDHandDelivery:[faxnumber,includingareacode]HElectronicMail:[addresswheredelivered,city,state,&zipcode]HElectronicMail:[addresswheredelivered,city,state,&zipcode] OCRSuspect[ electronicmail(email)address][electronicmail(email)address]DateofService:DateofService:[month,day,andyearthatthedocumentwasserved][month,day,andyearthatthedocumentwasserved]Aretheremorethantwopartiestobeserved?Yes OCRSuspectED NoEDIfso,attachalistofadditionalrecipientstothisform.[signyourname][printyourfullname] American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONSFORNOTICEOFAPPEALTheseinstructionsandformsareaproductoftheNebraskaWorkers222CompensationCourtandareprovidedasapublicservice.THENEBRASKAWORKERS222COMPENSATIONCOURTDOESNOTREPRESENTTHATTHESEINSTRUCTIONSANDFORMSWILLBEAPPROPRIATEINEVERYCASE.CASE-SPECIFICQUESTIONSSHOULDBEDIRECTEDTOALAWYER.COURTPERSONNELMAYNOTCOMPLETETHEFORMSFORYOU.TheNoticeofAppealisadocumentthatnotifiesthecourtandtheotherpartiesthatyouareappealingthedecisionoftheWorkers222CompensationCourt.Inordertomeetthestatutorydeadlineforappealandperfectyourappeal,youmustfileaNoticeofAppealwiththeWorkers222CompensationCourtclerk'sofficewithin30daysofthedateofthejudge222sdecision.Thefilingfeesshouldbepaidwitha$26checkpayable OCRSuspectto NebraskaCourtofAppealsanda$75checkpayabletoNebraskaWorkers222CompensationCourt.Alternatively,anAffidavitandApplicationtoProceedwithoutPaymentofCosts OCRSuspectmay befiled(formavailableonthePublications&FormssectionofWorkers222CompensationCourtwebsiteathttp:/ OCRSuspect/ www.wcc.ne.gOv OCRSuspect/ Dublications OCRSuspect/ publications.aspx#adi OCRSuspect) .Inaddition,uponfilingtheNoticeofAppeal,youshouldfile OCRSuspecta PraecipeforTranscriptand OCRSuspecta RequestforBillofExceptionsintheWorkers222CompensationCourtclerk222soffice.Formsandinstructionsforthesedocumentsareavailableonthecourt'swebsiteathttpd OCRSuspect/ www.wcc.ne.qov OCRSuspect/ publications OCRSuspect/ publications.aspxffadi.Generalquestionsregardingthisprocessmaybedirected OCRSuspectto thecourt222sinformationlineat800-599-5155or402-471-6468oryoumaycontactthecourtbyemailfromourwebsite OCRSuspect( http://www.wcc.ne.gov OCRSuspect) .Case-specificinquiriesshouldbedirectedtoalawyer,astheNebraskaWorkers222CompensationCourtcannotprovidelegaladvice.HEADINGEnterthesameheadingasitappearsonotherpreviously-fileddocumentsinyourcase.Ifyouareunsureoftheheadinginformation,youmaycontacttheclerk222sofficetoobtaintheinformation.BODYOFTHENOTICEOFAPPEALEnterwhichpartyyouwereinthetrialcourtaction(plaintiffordefendant(s))inthefirstblankprovided.Inthesecondblankprovided,indicatewhetherthedecisionyouareappealingwasanAward,anOrderofDismissal,or,ifanothertypeofdecision,enterthetitleofthedecision.Enterthedateofthedecisioninthethirdblank.Attachadditionalpages,ifneeded.Besuretoindicateintheblankspacethatadditionalpagesareattached.SIGNATURE,ADDRESS,ANDTELEPHONESignyournameinthespaceprovided. OCRSuspect Printyourfullnameinthespaceprovided. OCRSuspect Printyouraddressinthespaceprovided. OCRSuspect Printyourtelephonenumberinthespaceprovided.NOTE:Ifyouraddressorphonenumberchanges,contacttheclerk222sofficetoensurethatyouwillcontinuereceivingimportantnotificationsaboutyourcase.CERTIFICATEOFSERVICECourtrulesrequireproofthatyouservedcertaindocuments OCRSuspecton theotherpartiesinacase.Toserve OCRSuspectsomeone meansyouhavegiventhemacopyofthedocumentinawaythatispermittedunderNebraskaWorkers'CompensationCourtRule3,B,1(available OCRSuspecton thePublications&Formssectionofourwebsiteathttp: OCRSuspect/ /www.wcc.ne.gOv OCRSuspect/ publications OCRSuspect/ publications.aspx#adi OCRSuspect) .Thereareseveralmethodsofserviceavailable,butthemostcommonmethodisbymail.CompletetheCertificateofServicetoshowthatyousentacopyofthedocumenttotheotherparty(ies).Iftherearemorethantwoadditionalpartiestobeserved,checktheboxlabeled223Yes224andattachalistofadditionalrecipients.Ifnot,checkthe OCRSuspectbox labeled223No224.Enterthenameofeachpersonyouwillserve.Selectthecorrectmethodofservicebycheckingtheappropriateboxandenterthecorrespondinginformation(e.g.,forservicebymail,providetheaddressthatyouused).Youmayserveapartyviaemailorfaxonlyifthepartyhaspreviouslydesignatedanemailaddressorfaxnumberonapriordocument.SeeNebraskaWorkers222CompensationCourtRule3,B,1.Enterthedateofservice.SIGNATURESignyournameinthespaceprovided.Printyourfullnameinthespaceprovided.Onceyouhavecompletedtheform,makecopies.Sendtheoriginalform OCRSuspectto thecourtalongwiththeoriginalPraecipeforTranscriptandRequestforBillofExceptions.TheoriginalNoticeofAppealisforthecourtfile.Sendacopy OCRSuspectto eachpartyaccordingtotheservicemethodyouindicatedintheCertificateofService(seeabove).Keeponecopyforyourrecords.Youmaymail,fax,orhand-delivertheoriginalformtothecourt.Mailto:Faxto:Hand-deliver(ordeliverbyFedEx,UPS,etc.)to:NebraskaWorkers222CompensationCourt402-471-8231NebraskaWorkers222CompensationCourtP.O.Box989081010LincolnMall,Suite100LincolnNE68509-8908LincolnNE68508 American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONALINFORMATIONREGARDINGAPPEALSForinformationonanyadditionalrequirements,seetheNebraskaCourtRulesofAppellatePractice OCRSuspect( http: OCRSuspect/OCRSuspect/ suDremecourt.ne.aov OCRSuspect/ supreme-court-rules OCRSuspect/OCRSuspectch 2 OCRSuspect/ art OCRSuspect1OCRSuspect) andthe"Citizen222sGuidetotheNebraskaAppellateCourts224 OCRSuspect( httD://supremecourt. OCRSuspectne .aov/sites/supremecourt. OCRSuspectne .aov/files/self OCRSuspect- helD/citz-auide-aDPellate-courts.Ddf OCRSuspect) .APPEALDOCUMENTCHECKLISTTotheNebraskaWorkers222CompensationCourt:Theoriginal,completedNoticeofAppeal OCRSuspect A$26checkpayabletoNebraskaCourtofAppealsanda$75checkpayabletoNebraskaWorkers222CompensationCourt(orAffidavitandApplicationtoProceedwithoutPaymentofCosts)Theoriginal,completedPraecipeforTranscriptTheoriginal,completedRequestforBillofExceptionsTheAffidavitandApplicationtoProceedwithoutPaymentofCosts,ifapplicableToeachoftheotherparty(ies):OnecopyofthecompletedNoticeofAppealOne OCRSuspectcopy ofthecompletedPraecipeforTranscriptOne OCRSuspectcopy ofthecompletedRequestforBillofExceptionsTothecourtreporter:One OCRSuspectcopy ofthecompletedRequestforBillofExceptions OCRSuspect( contacttheclerk'soffice OCRSuspectto obtainthecourtreporter222scontactinformation).APPEALCOSTSGenerally,thepersonrequestingtheappealmustpaythecostsoftheappeal,unlessthe OCRSuspectcourt approvestheApplicationtoProceedwithoutPaymentofCosts.ThesecostsincludethecosttopreparetheBillofExceptions,thecosttopreparetheTranscript($1.00),thecashdeposit($75.00),theCourtofAppealscosts($26.00)andthecostsyouincurforprintingbriefs.YoumustpayforthecosttopreparetheBillofExceptions.ThecourtreporterwillgiveyouanestimateofthecosttopreparetheBillofExceptions,andyoumayhavetopayadepositbeforehe/shebeginspreparation. 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