State of Rhode Island and Providence Plantations Providence, Sc. ) ) ) ) ) Workers' Compensation Court VS. W.C.C. No. CLAIM OF APPEAL TO THE APPELLATE DIVISION The hereby files Division and will being aggrieved by the entry of said decree on claim of appeal to the Appellate will not request a transcript of the testimony. To request a transcript, the appellant must file form CC-12 (Request for Transcript) in accordance with the Procedure for Requesting a Transcript found on the Judiciary's website at www.courts.ri.gov . Signature of attorney for the appellant Print Attorney's Name and Registration Number The reasons of appeal, together with the transcript of testimony shall be filed on or before . /s/ Judge Revised Date American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 W.C.C. No. The time for filing reasons of appeal and the transcript of testimony is hereby extended to Judge The time for filing reasons of appeal and the transcript of testimony is hereby extended to Date Judge The time for filing reasons of appeal and the transcript of testimony is hereby extended to Date Judge The time for filing reasons of appeal and the transcript of testimony is hereby extended to Date Judge CERTIFICATE OF SERVICE Date I hereby certify that, on the ______ day of _____________________, ______: I electronically filed and served this document through the electronic filing system with notice to on the following parties: ______________________________________________________________________ _____________________________________________________________________________________. The document electronically filed and served is available for viewing and/or downloading from the Rhode Island Judiciary's Electronic Filing System. I served this document through the electronic filing system on the following parties: ________________ _____________________________________________________________________________________. The document electronically served is available for viewing and/or downloading from the Rhode Island Judiciary's Electronic Filing System. I mailed or hand-delivered this document to the attorney counsel for the opposing party (and/or the opposing party if self-represented,) whose name is__________________________________________ at the following address _________________________________________________________________. Revised American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2