IN THE COURT OF COMMON PLEAS OF MONTGOMERY COUNTY, PENNSYLVANIA : : : VS. : : NO. NOTICE OF APPEAL FROM AWARD OF BOARD OF ARBITRATORS TO THE PROTHONOTARY: Notice is given that ___________________________________________appeals from the award of arbitrators entered in this case on __________________________________________. A Jury Trial is Demanded Jury Trial Waived I hereby certify that: The compensation of the arbitrator has been paid or Application has been made for permission to proceed in forma pauperis ________________________________________ Print Name and Attorney ID Number ________________________________________ Signature CASE TO BE TRIED BY (PRINT NAMES AND ID NUMBERS OF ALL COUNSEL): NAMES AND ADDRESSES OF UNREPRESENTED PARTIES: COMPANION CASES: (2/11) American LegalNet, Inc. www.FormsWorkFlow.com