Fill and Sign the Court of Appeals State of Colorado Colorado Form

Noti ce of Appea l ICAO - DD11-2003I. AGENCY INFORMATION·Agency from which judicial review is sought: Industrial Claim Appeals Office·Agency case number ifDD: II. PROPOSED ISSUES ON APPEALPlease give ageneral andadvisory list of issues on appeal. You will be required to file a detailed opening brief 15 days after you receive notice that the record from the ICAO has been filed. If you need more space, attach a separate sheet. III. PARTY AND ATTORNEY INFORMATIONAllparties and the ICAO must be identified and a copy of the notice of appeal must be mailed to each. You may refer to the mailing information on the last page of the ICAO Final Order to find this information. If a party was represented by an attorney, then you should identify the attorney and that party should be served through the attorney.Respondent Employer/Employee:Attorney for Respondent:Attorney for Respondent ICAO:Office of the Attorney General(name)(name) Human Resources Section1525 Sherman St., 5th FloorDenver, CO 80203(address)(address)COURT OF APPEALS, STATE OF COLORADO 2 East Fourteenth Avenue, Suite 300 Denver, CO 80203 , Petitioner(Person/business initiating the appeal) V. INDUSTRIAL CLAIM APPEALS OFFICE and ,Respondents(All other parties to the appeal)___________________________________ Case #: _________________ (to be assigned by court)NOTICE OF APPEAL (C.A.R. 3.1Unemployment Insurance) Noti ce of Appea l ICAO - DD11-2003IV. APPENDIXYou must attach a complete copy of the ICAO Final Order, including the certificate of service. V. SIGNATUREYou must sign this notice of appeal and provide us with your address and phone number.Signature of PetitionerAddress of PetitionerBy:________________________________- Sign here -Phone #:The original and five (5) copies of this Notice of Appeal must be filed with the Clerk of the Court,Colorado Court of Appeals, 2 East 14th Ave., Suite 300, Denver, CO 80203.CERTIFICATE OF SERVICEYou must complete this certificate of service and mail or hand-deliver a complete copy of the notice of appeal to each party listed. I hereby certify that a true and correct copy of the foregoing NOTICE OF APPEAL together with complete copies of all attachments was: placed in the United States mail, properly addressed, postage prepaid, or hand-delivered, to each of the following parties this day of , 20 : Division of Employment & TrainingU.I. Benefits 251 East 12th Avenue Denver, CO 80203 Employer/Employee (name & address): ANDOffice of the Attorney General Human Resources Section 1525 Sherman St., 5th Floor Denver, CO 80203 Employer’s/Employee’s Attorney, if any:By: _____________________________________ (Signature of Petitioner)Please check theappropriate box to the right.