Appendix 4.15-2 Illustration for ORAP 4.15 — Petition for Review of Order of the Workers' Compensation Board
Appendices
Rule Text
Illustration for ORAP 4.15
(Workers' Compensation Case)
IN THE COURT OF APPEALS OF THE STATE OF OREGON
| In the Matter of | ) | |
| the Compensation of | ) | |
| ________________, Claimant. | ) | WCB Case No.________________ |
| ) | ||
| ___________________________, | ) | CA A____________ |
| Petitioner, | ) | |
| ) | ||
| v. | ) | |
| ___________________________, | ) | |
| Respondent. | ) |
PETITION FOR JUDICIAL REVIEW
OF ORDER OF THE WORKERS' COMPENSATION BOARD
Petitioner seeks judicial review of the Workers' Compensation Board Order on Review dated ________.
The parties to the judicial review proceeding before the Court of Appeals are:
| Petitioner(s) | Respondent(s) |
____________________________________________________________________________
____________________________________________________________________________
The name, bar number, address, telephone number, and email address of the attorney(s) for each party represented by an attorney is:
Name & Bar Number _____________________________ Representing __________________
Address ________________________________________ Telephone Number ______________ Email Address __________________________________
Name & Bar Number _____________________________ Representing __________________
Address ________________________________________ Telephone Number ______________ Email Address __________________________________
The name, address, and telephone number of each self-represented party is:
Name ____________________________________
Address___________________________________ Telephone Number ___________________
Email address
□ For self-represented parties: Please check here if you consent to receiving notices from the appellate court by email.
□ For self-represented parties: Please check here if you consent to receiving the agency record by Secure File Transmission Protocol (SFTP).
The relief sought and reason relief should be granted are:
__________________________
DATED this ________ day of _____________, ________.
________________________________ Attorney for Petitioner [Sign and print/type name, bar number, address, telephone number, and email address]
CERTIFICATE OF SERVICE
I certify that on [date] , I served a true copy of this petition for judicial review on:
Workers' Compensation Board
________________________________
________________________________
[address]
| ______________________________ | ______________________________ |
| ______________________________ | ______________________________ |
______________________________ ______________________________
[Other party(ies) or attorney for other party(ies)]
by [specify method of service]:
__ United States Postal Service, ordinary first class mail
__ United States Postal Service, certified or registered mail, return receipt requested __ hand delivery
__ other (specify) __________________________________
CERTIFICATE OF FILING
I certify that on [date] , I filed the original of this petition for judicial review with the
[Supreme Court or Court of Appeals, as appropriate] by [specify method of filing]:
__ United States Postal Service, ordinary first class mail
__ United States Postal Service, certified or registered mail, return receipt requested __ hand delivery
__ other (specify) __________________________________
____________________________________ [Signature of petitioner or attorney]
____________________________________ [Typed or printed name of petitioner or attorney]