DELAWARE COUNTY COURT OF COMMON PLEAS APPEAL FROM ARBITRATION AWARD CASE CAPTION: NO.___________________ TRIAL DATE: _________________ AWARD DATE: ________________ APPEAL DATE: ________________ COMPANION CASE (IF ANY) Notice is given that (party's name): ________________________________________________ appeals from the award of the board of arbitrators entered in this case. A jury trial is demanded. (Check box if a jury trial is demanded. Otherwise jury is waived, see Pa. R.C.P 1007.1 (b).) I hereby certify that: (check one box) the compensation of the arbitrators has been paid, or application has been made to proceed in forma pauperis. Plaintiff's Attorney Defendant's Attorney ____________________________________ Name ______________________________________ Name ____________________________________ Address _____________________________________ Address ____________________________________ ______________________________________ ____________________________________ ______________________________________ ____________________________________ Phone ______________________________________ Phone ____________________________________ Name _____________________________________ Address ______________________________________ Name ______________________________________ Address _____________________________________ ______________________________________ _____________________________________ ______________________________________ _____________________________________ Phone ______________________________________ Phone *Include additional names and addresses on back of form. Name and address of any Unrepresented Party: ___________________________________________________________ __________________________________________________________________________________________________ Signature: __________________________________________________________________Date:____________________ INSTRUCTIONS: This form must be completed in its entirety. No affidavit or verification is required. File in triplicate with the Office of Judicial Support. File separate appeal forms for each companion case. American LegalNet, Inc. www.FormsWorkflow.com