Free Form App. R. 9-2 Notice Of Appeal From Administrative Agency - Indiana

Form App. R. 9-2 Notice Of Appeal From Administrative Agency
) ) SS: ) IN THE [insert name of Administrative Agency] CASE NO. [insert Administrative Agency number]

STATE OF INDIANA

____________________________, Claimant(s), vs. ____________________________, Respondent(s). )

) ) ) ) ) ) ) )

NOTICE OF APPEAL FROM ADMINISTRATIVE AGENCY
[Insert designation and name of the party appealing], [by counsel or pro se - select one], pursuant to Ind. Appellate Rule 9(I), respectfully gives notice of an appeal from the following order(s) entered by the [insert the name of the Administrative Agency]: [list title(s) and date(s) of appealed order(s).] This appeal is from [a final order or an interlocutory order ­ select one.] This appeal will be taken to the Indiana Court of Appeals pursuant to Ind. Appellate Rule 5(C). Pursuant to Ind. Appellate Rule 10, the [insert name of administrative agency] is requested to assemble the Clerk's Record, as defined in Ind. Appellate Rule 2(E). Pursuant to Ind. Appellate Rule 11, the court reporter of the [insert name of the Administrative Agency] is requested to transcribe, certify, and file with the [insert name of Administrative Agency] the following hearings of record, including exhibits: [designate requested portions of the transcript]

Respectfully submitted,
_______________________________________

[Insert name of Attorney or pro se party] Address Telephone number

CERTIFICATE OF SERVICE

The undersigned hereby certifies that a copy of the foregoing has been served upon the following by [indicate method of service], this ____ day of __________, 20__: [insert list of parties served, see Ind. Appellate Rule 9(A)(1)]
________________________________________

[Insert name of Attorney or pro se party]

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