IN THE NEBRASKA WORKERS' COMPENSATION COURT _____________________________________________________________________________________ _____________________________________________________________________________________, [employee name] Plaintiff, vs. _____________________________________________________________________________________ _____________________________________________________________________________________, [name of employer or name of employer and insurance company] Defendant(s). ) ) ) ) ) ) ) ) ) ) ) ) Docket: ___________________________ Page: ____________________________ REQUEST FOR BILL OF EXCEPTIONS TO: CLERK OF THE NEBRASKA WORKERS' COMPENSATION COURT and ______________________________________________________________, Court Reporter: [name of court reporter] Please transcribe and prepare a Bill of Exceptions which will contain all testimony, exhibits, and evidence offered at the trial/ hearing(s) on _____________________________________________________________________________ in the above-captioned matter. [date(s)] ___________________________________________________________________________________________ [sign your name] ___________________________________________________________________________________________ [print your street address] ___________________________________________________________________________________________ [print your telephone number] ___________________________________________________________________________________________ [print your full name] ___________________________________________________________________________________________ [print your city, state, & zip code] Note: See other side of this form for instructions. Please keep the court informed if you change your address or phone number. CERTIFICATE OF SERVICE The undersigned hereby certifies that a copy of the above Request for a Bill of Exceptions was served upon: [Check one method of service for each party served] Name: __________________________________________________________________________________ [name of court reporter] [street address] Name: __________________________________________________________________________________ [name of service recipient] [street address] Mail: ________________________________________________________________________________ _______________________________________________________________________________ [city, state, & zip code] Mail: ________________________________________________________________________________ _______________________________________________________________________________ [city, state, & zip code] Fax: ________________________________________________________________________________ [fax number, including area code] Fax: ________________________________________________________________________________ [fax number, including area code] Hand Delivery: _____________________________________________________________________ [address where delivered, city, state, & zip code] [electronic mail (e-mail) address] Hand Delivery: _____________________________________________________________________ [address where delivered, city, state, & zip code] [electronic mail (e-mail) address] Electronic Mail: ______________________________________________________________________ Date of Service: ______________________________________________________________________ [month, day, and year that the document was served] Electronic Mail: _____________________________________________________________________ Date of Service: ______________________________________________________________________ [month, day, and year that the document was served] Name: __________________________________________________________________________________ [name of service recipient] [street address] Are there more than three parties to be served? Yes No Mail: ________________________________________________________________________________ _______________________________________________________________________________ [city, state, & zip code] If so, attach a list of additional recipients to this form. Fax: ________________________________________________________________________________ [fax number, including area code] Hand Delivery: _____________________________________________________________________ [address where delivered, city, state, & zip code] [electronic mail (e-mail) address] Electronic Mail: ______________________________________________________________________ Date of Service: ______________________________________________________________________ [month, day, and year that the document was served] ___________________________________________________________________________________________ [sign your name] ___________________________________________________________________________________________ [print your full name] American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR REQUEST FOR BILL OF EXCEPTIONS These instructions and forms are a product of the Nebraska Workers' Compensation Court and are provided as a public service. THE NEBRASKA WORKERS' COMPENSATION COURT DOES NOT REPRESENT THAT THESE INSTRUCTIONS AND FORMS WILL BE APPROPRIATE IN EVERY CASE. CASE-SPECIFIC QUESTIONS SHOULD BE DIRECTED TO A LAWYER. COURT PERSONNEL MAY NOT COMPLETE THE FORMS FOR YOU. The Bill of Exceptions is made up of the trial evidence, which includes written documents (exhibits) and a copy of the oral testimony from trial (trial transcript). The Request for Bill of Exceptions should be filed at the same time the Notice of Appeal is filed with the Workers' Compensation Court. If you do not request a Bill of Exceptions, the judges will not be able to review the trial evidence, and that may compromise your case on appeal. The Bill of Exceptions is prepared by the court reporter. You must pay for the cost to prepare the Bill of Exceptions. The court reporter will give you an estimate of the cost to prepare the Bill of Exceptions, and you may have to pay a deposit before he/she begins preparation. General questions regarding this process may be directed to the court's information line at 800-599-5155 or 402-471-6468 or you may contact the court by e-mail from our web site (http://www.wcc.ne.gov). Case-specific inquiries should be directed to a lawyer, as the Nebraska Workers' Compensation Court cannot provide legal advice. WHEN A PARTY IS UNABLE TO PAY APPEAL COSTS If you are unable to pay or secure the means to pay for the costs of an appeal, you can request the court to waive