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ILLINOIS WORKERS' COMPENSATION COMMISSION 100 W. RANDOLPH ST. #8-200 CHICAGO, IL 60601

_________________________________
Petitioner

Case #

______ WC _________

v. _________________________________
Respondent

Commissioner ____________________ Return date ____________________

TRANSCRIPT RECEIPT FORM

The Illinois Workers' Compensation Commission acknowledges receipt of the arbitration transcript for this case.

_________________________
Signature of IWCC employee

Attention, parties. When you authenticate the transcript and return it to the Docket unit, please submit it with two copies of this completed form. If you mail the transcript in, please include a self-addressed stamped envelope. One copy will be datestamped and returned to you. ICTR 1/08