Fill and Sign the In an Administrative Appeal Request Alaska Form

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT _____________________ ) ) ) Appellant (person br inging appeal) ) ) vs. ) ) ) ) APPEAL CASE NO. CI Appellee ) ) CASH DEPOSIT ON APPEAL I am depositing cash in lieu of a bond as describe d below . I understand that if the appeal is dism issed or if the judg ment/decisio n is af firm ed or m odified, the court m ay order that part or all of this cash deposit be p aid to the ap pelle e to co ver appea l costs, and if the cash dep osit is in lieu of a supersedeas bond the court may also order that it be pa id to the appellee to pay the judgm ent, post-judgm ent costs and interest. If the court reverses the judgm ent/decision, the money I am depositing will be retu rned to m e without interest. Cash deposit in the am ount of $_________ in lieu of a Cost Bond . I understand that this deposit will not result in a stay of exec ution of the judgm ent. Cash deposit in the am ount of $_________ in lieu of a Supersedeas Bo nd . I understand that this deposit will stay execution of the judgm ent. I am the owner of the cash deposited. I subm it myself to the ju ris diction of the court an d irrevocably appoint the clerk of court as m y agent upon whom any papers affecting this deposit may be served. I agree that it is not necessary for an independent action to be filed in order for this deposit to be used as described above. Date Signature of Owner of Cash Type or Print Nam e Telephone No. Mailing Address City State Zip ACKNOWL EDGMENT The foregoing instrum ent was acknowledged before m e this date, __________________, 20___, by ___________________________, who personally appeared before me and ac\ knowledged that he/she executed the instrum ent fo r the purposes stated in it. (SEAL) Clerk of Court/Notary Public My comm ission expires: I certify that on a copy of this for m was m ailed personally delivered Am t. Deposited $________ Date ___________ to (list n ames): Receipt No. ____________ Clerk _____ ______ By: AP-110 (1/05)(cs) App. R. 204(c), 602(g) CASH DEPOSIT ON APPEAL Civil Rule 8 0(f) & (g)