§ Form No. 9 Petition for review

Form No. 9. Petition for review

IN THE SUPREME COURT OF THE STATE OF OKLAHOMA

___________________________________ )

___________________________________, )

)

Petitioner, )

)

v. ) No. _______________

)

___________________________________ )

_____________________, and )

THE WORKERS' )

COMPENSATION )

COURT, )

)

Respondents. )

PETITION FOR REVIEW

A. WORKERS' COMPENSATION COURT HISTORY

Number and style of proceeding in the court: _________________________________

Decision to be reviewed was rendered by: (Check one)

() The Workers' Compensation Court en banc, or

() A Judge of the Court.

Date of filing of the decision to be reviewed?_________________________________

Date a copy of the decision was sent to the parties? _________________________

.
If seeking a review of the decision of the court en banc, also give date of the decision by the trial judge: _______, and the date an appeal was brought to the tribunal en banc: _______ (Otherwise mark N/A).

B. DISPOSITION IN THE WORKERS' COMPENSATION COURT

Nature of the decision to be reviewed ________________________________________

________________________________________

Relief sought: _______________________________________________________________

Relief granted: ______________________________________________________________

(Attach a certified copy of the decision to be reviewed as exhibit “A”.)

A copy of the clerk's certificate that the employer has an approved statutory bond on file with the court also is attached hereto ___ Yes ___ No

(Required only if review is sought by employer or insurance carrier from a decision awarding benefits to claimant).

C. BRIEF SUMMARY OF PROCEEDING

Exhibit “B” attached (not to exceed one 8 1/2 ” x 11” double spaced page).

D. ISSUES AND ERRORS PROPOSED TO BE RAISED ON APPEAL

Exhibit “C” attached. (Number and state with specificity each point urged as error.) (General assignments will not suffice.)

ANY RELATED OR PRIOR APPEALS? ___ YES ___ NO

(Identify by style, citation, if any, and Supreme Court Number.)

Style Citation Supreme Court No.

_________________________ _________________________ _________________________

E. ATTORNEY FOR PETITIONER ATTORNEY FOR RESPONDENT

Name: ______________________________________ Name: ______________________________________

Firm: ______________________________________ Firm: ______________________________________

Address: ______________________________________ Address: ______________________________________

______________________________________ ______________________________________

Telephone: ______________________________________ Telephone: ______________________________________

(Give the name and address of the party if unrepresented)

Date: _______________, 19___

Verified by: ___________________________________________

(Signature of Attorney or Pro Se Party)

OBA No.: ___________________________________________

Firm: ___________________________________________

Address: ___________________________________________

___________________________________________

Telephone: ___________________________________________

CERTIFICATE OF FILING AND MAILING

I _______, do hereby certify that on this ____ day of _______6d, 19___, I did cause to be filed with the Workers' Compensation Court, a correct copy of the Petition for Review with attachment(s), and also mailed a copy with attachment(s), postage prepaid to each party to the proceeding or his counsel of record as follows:

[Names and addresses of all parties or counsel of record]

________________________________________________________________________________

Adopted July 10, 1996

Effective January 1, 1997

Heading renumbered by order of May 5, 2005, which added a new Part IX.