DC-40 (revised October 2017) Page 1 of 2 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT APPEAL FORM Rhode Island General Laws 1956 247 28-44-52 establishes the right to appeal within thirty (30) days of notice of decision. The fee for this appeal is $100.75. You must complete this form and state your reasons for this appeal on the second page of this form. (Attach additional pages if necessary). If your appeal does not show sufficient grounds, it will be denied. Failure to file this Appeal Form and pay the fee within thirty (30) days of decision will deny your opportunity for an appeal. This is an appeal from a decision by: Department of Labor and Training Board of Review COMPLETE THE FOLLOWING: Name of Party Date: Date of Birth: Address: Home Telephone Number: Cell Number: Email Address: ATTORNEY OF RECORD MUST FILL OUT THE FOLLOWING: /s/ Signature of the Attorney Rhode Island Bar Number: Date: Address: Office Telephone Number: Cell Number: Email Address: American LegalNet, Inc. www.FormsWorkFlow.com DC-40 (revised October 2017) Page 2 of 2 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT STATE REASONS FOR APPEAL BELOW American LegalNet, Inc. www.FormsWorkFlow.com