Index of ICA Forms – Page 1 of 2
INDEX OF ICA FORMS SPECIAL NOTE: IF THE PETITIONER IS THE APPLICANT/EMPLOYEE THEN FORM (a) SHOULD BE USED. IF THE PETITIONER IS THE EMPLOYER/INSURANCE CARRIER, THEN FORM (b) SHOULD BE USED. Information to complete the forms should be TYPED rather than hand-written. Form 1 Form 2 Form 3(a) Form 3(b) Form 4(a) Form 4(b) Form 5(a) Form 5(b) Form 6(a) Form 6(b) Form 7(a) Form 7(b) Form 8(a) Form 8(b) Form 9(a) Form 9(b) Notice of Change of Address with the ICA Request for Review Notice of Change of Address (Court of Appeals) Notice of Change of Address (Court of Appeals) Notice of Change of Address (Arizona Supreme Court) Notice of Change of Address (Arizona Supreme Court) Petition for Special Action – Industrial Commission Petition for Special Action – Industrial Commission Notice of Appearance Notice of Appearance Application for Deferral or Waiver of Court Fees and/or Costs Application for Deferral or Waiver of Court Fees and/or Costs Petitioner’s Opening Brief / Respondent’s Answering Brief / Petitioner’s Reply Brief Petitioner’s Opening Brief / Respondent’s Answering Brief / Petitioner’s Reply Brief Motion for Extension of Time to File Brief Motion for Extension of Time to File Brief
Form 10(a) Stipulation for Extension of Time to File Brief Form 10(b) Stipulation for Extension of Time to File Brief
Index of ICA Forms – Page 1 of 2
INDEX OF ICA FORMS
Form 11(a) Request for Oral Argument Form 11(b) Request for Oral Argument Form 12(a) Statement of Costs Form 12(b) Statement of Costs Form 13(a) Petition for Review (filed in the Court of Appeals) Form 13(b) Petition for Review (filed in the Court of Appeals) Form 14(a) Response to Petition for Review (filed in the Arizona Supreme Court) Form 14(b) Response to Petition for Review (filed in the Arizona Supreme Court)
SPECIAL NOTE: IF AN OPPOSING PARTY IS REPRESENTED BY AN ATTORNEY, THESE FORMS MUST BE SERVED ON THE ATTORNEY FOR THE PARTY, RATHER THAN ON THE OPPOSING PARTY.
Notice of Change of Address with the ICA / Form 1 – Page 1 of 2
[Date]: ________________
Industrial Commission of Arizona 2675 E. Broadway Tucson, AZ 85716 Re: Applicant: ICA Claim No.: Ins. Claim No.: Date of Injury:
Industrial Commission of Arizona 800 W. Washington Street Phoenix, AZ 85007
_____________________________ _____________________________ _____________________________ _____________________________
Dear Sir/Madam: This is to inform you of a change of address effective [date] ______________ , 200___ for [Applicant/Employer] ________________________. Please change address from: Old Address: ________________________________ ________________________________ ________________________________
To New Address: ________________________________ ________________________________ ________________________________ Sincerely,
__________________________________ [Applicant/Employer]
Notice of Change of Address Industrial Commission / Form 1 – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Applicant/Employer] on the ____ day of ___________, 200___, mailed an Original of the Notice of Change of Address either the Tucson or Phoenix office of the ICA; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Insurance Carrier or Counsel ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ______________
__________________________________ [Applicant/Employer]
Request for Review / Form 2 – Page 1 of 2
THE INDUSTRIAL COMMISSION OF ARIZONA
_____________________________ Applicant, v. _____________________________ EMPLOYER Respondent ______________________________ INSURANCE CARRIER Respondent
ICA Claim No. ______________ Ins. Claim No. ______________ Date of Injury: ______________
REQUEST FOR REVIEW
(The Honorable ________________)
Pursuant A.R.S. § 23-942(D) and A.R.S. § 23-943(A) and (B), _______________________ [Petitioner/Respondent] files his/her Request for Review of the Decision Upon Hearing and Findings and Award dated _____________, 200__ and maintains that the Award is not justified by the evidence and is contrary to law.* Dated: __________________
Print Name [Petitioner/Respondent] ________________________________________ Signature
Address
*This request may be accompanied by a memorandum of points and authority in support of the Request.
Request for Review / Form 2 – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original of the Request for Review in the ICA; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _____________________
__________________________________ [Petitioner/Respondent]
Notice of Change of Address (Court of Appeals) / Form 3(a) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____ _____________________________ APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent, _____________________________ EMPLOYER Respondent _____________________________ INSURANCE CARRIER Respondent The party signing this document is the _______________________________ [Petitioner/ Respondent]. This party advises this Court that ____________ [his/her] address has changed. This party’s current address is as follows:
______________________________________________________________________________ ______________________________________________________________________________
No. __ CA-IC _______________ ICA No. ____________________ Carrier No. _________________
NOTICE OF CHANGE OF ADDRESS
[Full address and phone number]. Dated:____________________ ________________________________________ Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Notice of Change of Address (Court of Appeals) / Form 3(a) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Notice of Change of Address in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _______________
__________________________________
[Petitioner/ Respondent]
Notice of Change of Address (Court of Appeals) / Form 3(b) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. __ CA-IC ___________________ ICA No. _______________________ Carrier No. _____________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
NOTICE OF CHANGE OF ADDRESS
APPLICANT Respondent The party signing this document is the _______________________________ [Petitioner/ Respondent]. This party advises this Court that ____________ [his/her] address has changed. This party’s current address is as follows:
______________________________________________________________________________ ______________________________________________________________________________
[Full address and phone number]. Dated:____________________
________________________________________
Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Notice of Change of Address (Court of Appeals) / Form 3(b) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Notice of Change of Address in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ________________
__________________________________ [Petitioner/ Respondent]
Notice of Change of Address (Arizona Supreme Court) / Form 4(a) – Page 1 of 2
ARIZONA SUPREME COURT
__________________________________
No. ___ CA-IC _____________ ICA No. ___________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________
NOTICE OF CHANGE OF ADDRESS
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent The party signing this document is the ____________________________ [Petitioner/ Respondent]. This party advises this Court that ______ [his/her] address has changed. This party’s current address is as follows: ________________________________________________
__________________________________________________________________________________
[Full address and phone number]. Dated:____________________ ________________________________________ Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Notice of Change of Address (Arizona Supreme Court) / Form 4(a)– Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and seven (7) copies of the Notice of Change of Address in the Arizona Supreme Court; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _____________________
__________________________________ [Petitioner/ Respondent]
Notice of Change of Address (Arizona Supreme Court) / Form 4(b) – Page 1 of 2
ARIZONA SUPREME COURT
__________________________________
No. ___ CA-IC _____________ ICA No. ___________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
NOTICE OF CHANGE OF ADDRESS
APPLICANT Respondent
The party signing this document is the ____________________________ [Petitioner/ Respondent]. This party advises this Court that ______ [his/her] address has changed. This party’s current address is as follows: ________________________________________________
___________________________________________________________________________________
[Full address and phone number]. Dated:____________________ ________________________________________ Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Notice of Change of Address (Arizona Supreme Court) / Form 4(b)– Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and seven (7) copies of the Notice of Change of Address in the Arizona Supreme Court; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _________________
__________________________________
[Petitioner/ Respondent]
Petition for Special Action – Industrial Commission / Form 5(a) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ONE
__________________________________
No. ___ CA-IC ______________ ICA No. ____________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________ PETITION FOR SPECIAL ACTION – INDUSTRIAL COMMISSION
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent Petitioner(s) request that the Court of Appeals review the award of the Industrial Commission in ICA No. __________, dated __________, and the decision on review, dated __________, and that the Clerk of the Court of Appeals issue a Writ of Review directing the Industrial Commission to certify its records, proceedings and evidence in this matter to the Court of Appeals. Dated: _______________ ________________________________________ Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Petition for Special Action – Industrial Commission / Form 5(a) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the Petition for Special action – Industrial Commission in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: __________________________________
__________________________________ [Petitioner/ Respondent]
Petition for Special Action – Industrial Commission / Form 5(b) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ONE
__________________________________
No. ___ CA-IC ______________ ICA No. ____________________ Carrier No. _________________ PETITION FOR SPECIAL ACTION – INDUSTRIAL COMMISSION
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
APPLICANT Respondent Petitioner(s) request that the Court of Appeals review the award of the Industrial Commission in ICA No. __________, dated __________, and the decision on review, dated __________, and that the Clerk of the Court of Appeals issue a Writ of Review directing the Industrial Commission to certify its records, proceedings and evidence in this matter to the Court of Appeals. Dated: _______________
________________________________________
Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Petition for Special Action – Industrial Commission / Form 5(b) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the Petition for Special action – Industrial Commission in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ________________________
__________________________________ [Petitioner/ Respondent]
Notice of Appearance / Form 6(a) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. __ CA-IC _______________ ICA No. ____________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________
NOTICE OF APPEARANCE
EMPLOYER Respondent _____________________________ INSURANCE CARRIER Respondent Pursuant to Rule 10(f), Rules of Procedure for Special actions, Respondent(s) give(s) notice of intention to participate in the determination of the above-captioned matter before the Court of Appeals. Dated:____________________
________________________________________
Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Notice of Appearance / Form 6(a) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Notice of Appearance in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _______________
__________________________________ [Petitioner/ Respondent]
Notice of Appearance / Form 6(b) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. __ CA-IC ______________ ICA No. ___________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
NOTICE OF APPEARANCE
APPLICANT Respondent Pursuant to Rule 10(f), Rules of Procedure for Special actions, Respondent(s) give(s) notice of intention to participate in the determination of the above-captioned matter before the Court of Appeals. Dated:____________________ ________________________________________ Print Name [Petitioner/ Respondent] ________________________________________ Signature ________________________________________ Address
Notice of Appearance / Form 6(b) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Notice of Appearance of Address in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _______________
__________________________________ [Petitioner/ Respondent]
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(a) – Page 1 of 6
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ___________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________
APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent STATE OF ARIZONA ) ) ss. COUNTY OF ________ ) STATEMENTS MADE TO THE COURT UNDER OATH OR AFFIRMATION. I swear or affirm that the information in this application is true and correct. I make this statement under the penalty of prosecution for perjury if it is determined that I did not tell the truth. I am requesting a deferral or waiver of the fees and costs in my case. The basis for this request is: 1. _____ WAIVER: I am permanently unable to pay. My income and liquid assets are insufficient or barely sufficient to meet the daily essentials of life and unlikely to change in the foreseeable future. OR
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(a) – Page 2 of 6
2. _____ FURTHER DEFERRAL _____ a. I receive government assistance from the state/federal program(s) checked below: _____ Temporary Assistance for Needy Families (TANF) _____ Food Stamps _____ Supplemental Security Income (SSI) _____ General Assistance (GA)
If you checked any of the above boxes in 1 or 2, you must complete the Financial Questionnaire. You must submit proof that you receive government assistance. If you are submitting this application by mail or a third party, you must attach a photocopy of that proof. OR _____ b. My income is sufficient or is barely sufficient to meet the daily essentials of life, and includes no allotment that could be budgeted for the fees and costs that are required to gain access to the court.
To determine whether income is sufficient or barely sufficient, the court will review your income and expenses. Among the factors the court may consider are: 1. Whether your gross income as computed on a monthly basis is 150% or less of the current federal poverty level. Gross monthly income includes your share of community property income if available to you. Although your income is greater than 150% of the poverty level, you have proof of extraordinary expenses, including medical expenses, costs of care for elderly or disabled family members or other expenses that the court finds are extraordinary and that reduce your gross monthly income to at or below 150% of the poverty level. OR _____ c. I do not have the money to pay court filing fees and/or costs now. I can pay the filing fees and/or costs at a later date. Explain:
2.
If you checked either boxes 2b or 2c, you must complete the Financial Questionnaire.
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(a) – Page 3 of 6
FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List all persons you support (including those for whom you pay child support and/or spousal maintenance/support). NAME _____________________________ _____________________________ _____________________________ _____________________________ STATEMENT OF INCOME AND EXPENSES ASSISTANCE: I receive assistance from: _____ Arizona Health Care Cost Containment System (AHCCCS) _____ Arizona Long Term Care System (ALTUS) _____ Other (explain): MONTHLY INCOME: My monthly income is: Monthly gross income: $ Employer name: Employer address: Employed since (month/year): Other current monthly income including spousal maintenance/support, retirement, rental, interest, pensions, scholarships, grants, royalties, lottery winnings (explain amount and source): $__________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ My spouse’s monthly gross income (if available to me): $_______________
RELATIONSHIP _____________________________ _____________________________ _____________________________ _____________________________
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(a) – Page 4 of 6
MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are: Payment Amount $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $_________________ Loan Balance $ $
$
Rent/Mortgage Payment Car Payment Credit Card Payments Other Payments and Debts Explain: Food/Household supplies Utilities/Telephone Clothing Medical/Dental/Drugs Health Insurance Nursing Care Laundry Child Support Child Care Spousal Maintenance Car Insurance Gasoline/Bus Fare Contributions to Employer or other retirement account TOTAL MONTHLY PAYMENTS:
$
STATEMENT OF ASSETS. List only those assets available to you and accessible without financial penalty. Equity is defined as market value minus any liens or loans. Cash and Bank Accounts Credit Union Accounts Equity in: Home Other Property Cars and other vehicles Other, including stocks, bonds, etc. Retirement Accounts TOTAL ASSETS: ESTIMATED VALUE $ $ $ $ $ $ $ $_________________
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(a) – Page 5 of 6
EXTRAORDINARY EXPENSES: For example, unusual medical needs, financial hardship, costs of care of elderly or disabled family members. (Proof must be submitted.) DESCRIPTION AMOUNT $ $ $_________________
TOTAL EXTRAORDINARY EXPENSES:
SIGNATURE UNDER PENALTY OF PERJURY Dated:
Print Name
Signature [Applicant/Employer]
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(a) – Page 6 of 6
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Application for Deferral or Waiver of Court Fees and/or Costs in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _____________________
__________________________________ [Petitioner/Respondent]
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(b) – Page 1 of 6
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ____________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
APPLICATION FOR DEFERRAL OR WAIVER OF COURT FEES AND/OR COSTS
APPLICANT Respondent STATE OF ARIZONA ) ) ss. COUNTY OF ________ ) STATEMENTS MADE TO THE COURT UNDER OATH OR AFFIRMATION. I swear or affirm that the information in this application is true and correct. I make this statement under the penalty of prosecution for perjury if it is determined that I did not tell the truth. I am requesting a deferral or waiver of the fees and costs in my case. The basis for this request is: 1. _____ WAIVER: I am permanently unable to pay. My income and liquid assets are insufficient or barely sufficient to meet the daily essentials of life and unlikely to change in the foreseeable future. OR
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(b) – Page 2 of 6
2. _____ FURTHER DEFERRAL _____ a. I receive government assistance from the state/federal program(s) checked below: _____ Temporary Assistance for Needy Families (TANF) _____ Food Stamps _____ Supplemental Security Income (SSI) _____ General Assistance (GA)
If you checked any of the above boxes in 1 or 2, you must complete the Financial Questionnaire. You must submit proof that you receive government assistance. If you are submitting this application by mail or a third party, you must attach a photocopy of that proof. OR _____ b. My income is sufficient or is barely sufficient to meet the daily essentials of life, and includes no allotment that could be budgeted for the fees and costs that are required to gain access to the court.
To determine whether income is sufficient or barely sufficient, the court will review your income and expenses. Among the factors the court may consider are: 1. Whether your gross income as computed on a monthly basis is 150% or less of the current federal poverty level. Gross monthly income includes your share of community property income if available to you. Although your income is greater than 150% of the poverty level, you have proof of extraordinary expenses, including medical expenses, costs of care for elderly or disabled family members or other expenses that the court finds are extraordinary and that reduce your gross monthly income to at or below 150% of the poverty level. OR _____ c. I do not have the money to pay court filing fees and/or costs now. I can pay the filing fees and/or costs at a later date. Explain:
2.
If you checked either boxes 2b or 2c, you must complete the Financial Questionnaire.
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(b) – Page 3 of 6
FINANCIAL QUESTIONNAIRE SUPPORT RESPONSIBILITIES: List all persons you support (including those for whom you pay child support and/or spousal maintenance/support). NAME
_____________________________ _____________________________ _____________________________ _____________________________
RELATIONSHIP
_____________________________ _____________________________ _____________________________ _____________________________
STATEMENT OF INCOME AND EXPENSES ASSISTANCE: I receive assistance from: _____ Arizona Health Care Cost Containment System (AHCCCS) _____ Arizona Long Term Care System (ALTUS) _____ Other (explain): MONTHLY INCOME: My monthly income is: Monthly gross income: $ Employer name: Employer address: Employed since (month/year): Other current monthly income including spousal maintenance/support, retirement, rental, interest, pensions, scholarships, grants, royalties, lottery winnings (explain amount and source): $_________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
My spouse’s monthly gross income (if available to me):
$_______________
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(b) – Page 4 of 6
MONTHLY EXPENSES AND DEBTS: My monthly expenses and debts are: Rent/Mortgage Payment Car Payment Credit Card Payments Other Payments and Debts Explain: Food/Household supplies Utilities/Telephone Clothing Medical/Dental/Drugs Health Insurance Nursing Care Laundry Child Support Child Care Spousal Maintenance Car Insurance Gasoline/Bus Fare Contributions to Employer or other retirement account TOTAL MONTHLY PAYMENTS: Payment Amount $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $_________________ Loan Balance $ $ $ $
STATEMENT OF ASSETS. List only those assets available to you and accessible without financial penalty. Equity is defined as market value minus any liens or loans. Cash and Bank Accounts Credit Union Accounts Equity in: Home Other Property Cars and other vehicles Other, including stocks, bonds, etc. Retirement Accounts TOTAL ASSETS: ESTIMATED VALUE $ $ $ $ $ $
$
$_________________
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(b) – Page 5 of 6
EXTRAORDINARY EXPENSES: For example, unusual medical needs, financial hardship, costs of care of elderly or disabled family members. (Proof must be submitted.) DESCRIPTION AMOUNT $ $ TOTAL EXTRAORDINARY EXPENSES: $_________________
SIGNATURE UNDER PENALTY OF PERJURY Dated:
Print Name
Signature [Applicant/Employer]
Application for Deferral or Waive Appeal Court Fees or Costs / Form 7(b) – Page 6 of 6
PROOF OF SERVICE
The undersigned _____________________________ [Applicant/Employer] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Application for Deferral or Waiver of Court Fees and/or Costs in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ________________________
__________________________________ [Applicant/Employer]
Form of Brief / Form 8(a) – Page 1 of 9
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ____________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent [PETITIONER’S OPENING BRIEF] [RESPONDENT’S ANSWERING BRIEF] OR [PETITIONER’S REPLY BRIEF]
__________________________________
Print Name [Petitioner/Respondent]
__________________________________
Signature
__________________________________
Address [USE APPROPRIATE COLOR FOR THE COVER] Cover page of Opening Brief is BLUE Cover page of Answering Brief is RED Cover page of Reply Brief is GRAY
Form of Brief / Form 8(a) – Page 2 of 9
TABLE OF CONTENTS [page] Table of Citations ................................................................................................................ Statement of the Case .......................................................................................................... Statement of Facts ............................................................................................................... Issues Presented for Review ................................................................................................ Argument I. .................................................................................................................................... A. Standards of Appellate Review .................................................................... ...................................................................................................................... 1.................................................................................................................... 2.................................................................................................................... II. ................................................................................................................................... A. Standards of Appellate Review .................................................................... B. .......................................................................................................................... Conclusion ........................................................................................................................... Certificate of Compliance ................................................................................................... Certificate of Service ........................................................................................................... B.
Form of Brief / Form 8(a) – Page 3 of 9
STATEMENT OF THE CASE (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(a) – Page 4 of 9
STATEMENT OF FACTS (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(a) – Page 5 of 9
ISSUE(S) PRESENTED (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(a) – Page 6 of 9
ARGUMENT (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(a) – Page 7 of 9
CONCLUSION
[Date]
_________________________________________ [Print Name] [Petitioner/Respondent] _________________________________________ [Signature]
_________________________________________ [Address]
Form of Brief / Form 8(a) – Page 8 of 9
CERTIFICATE OF COMPLIANCE Pursuant to ARCAP 14(b), I certify that the attached brief: ____ Uses proportionately spaced type of 14 points or more, is double spaced using a Roman font, and contains _________ words; OR Uses monospaced type of no more than 10.5 characters per inch and Does not exceed 40 pages [if Opening or Answering Brief] Does not exceed 20 pages [if Reply Brief]
____ ____ ____
Dated: _________________
Print Name [Petitioner/Respondent] _______________________________ Signature
Address
Form of Brief / Form 8(a) - Page 9 of 9
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the _________________________________________ [Petitioner’s Opening Brief, Respondent’s Answering Brief, or Petitioner’s Reply Brief] in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ______________________
__________________________________
[Petitioner/Respondent]
Form of Brief / Form 8(b) – Page 1 of 9
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ____________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
APPLICANT Respondent
[PETITIONER’S OPENING BRIEF] [RESPONDENT’S ANSWERING BRIEF] OR [PETITIONER’S REPLY BRIEF]
__________________________________
Print Name [Petitioner/Respondent]
__________________________________
Signature
__________________________________
Address [USE APPROPRIATE COLOR FOR THE COVER] Cover page of Opening Brief is BLUE Cover page of Answering Brief is RED Cover page of Reply Brief is GRAY
Form of Brief / Form 8(b) – Page 2 of 9
TABLE OF CONTENTS [page] Table of Citations ................................................................................................................ Statement of the Case .......................................................................................................... Statement of Facts ............................................................................................................... Issues Presented for Review ................................................................................................ Argument I. .................................................................................................................................... A. Standards of Appellate Review .................................................................... ...................................................................................................................... 1.................................................................................................................... 2.................................................................................................................... II. ................................................................................................................................... A. Standards of Appellate Review .................................................................... B. .......................................................................................................................... Conclusion ........................................................................................................................... Certificate of Compliance ................................................................................................... Certificate of Service ........................................................................................................... B.
Form of Brief / Form 8(b) – Page 3 of 9
STATEMENT OF THE CASE (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(b) – Page 4 of 9
STATEMENT OF FACTS (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(b) – Page 5 of 9
ISSUE(S) PRESENTED (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(b) – Page 6 of 9
ARGUMENT (*Add additional sheets of paper as necessary to complete this section)
Form of Brief / Form 8(b) – Page 7 of 9
CONCLUSION
[Date]
_________________________________________
[Print Name] [Petitioner/Respondent]
_________________________________________
[Signature]
_________________________________________
[Address]
Form of Brief / Form 8(b) – Page 8 of 9
CERTIFICATE OF COMPLIANCE Pursuant to ARCAP 14(b), I certify that the attached brief: ____ Uses proportionately spaced type of 14 points or more, is double spaced using a Roman font, and contains _________ words; OR Uses monospaced type of no more than 10.5 characters per inch and Does not exceed 40 pages [if Opening or Answering Brief] Does not exceed 20 pages [if Reply Brief]
____ ____ ____
Dated: _________________
Print Name [Petitioner/Respondent]
___________________________________
Signature Address
Form of Brief / Form 8(b) - Page 9 of 9
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the _____________________________________________ [Petitioner’s Opening Brief, Respondent’s Answering Brief, or Petitioner’s Reply Brief] in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _________________
__________________________________ [Petitioner/Respondent]
Motion for Extension of Time to File Brief / Form 9(a) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. __ CA-IC _______________ ICA No. ___________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________
MOTION FOR EXTENSION OF TIME TO FILE BRIEF
EMPLOYER Respondent _____________________________ INSURANCE CARRIER Respondent
_______________________ [Petitioner/Respondent] requests an extension of time
within which to file ________________ [his/hers] __________________ [Opening/ Answering/Reply] Brief from _______________________ [Date Currently Due] to _____________________ [New Date] for the reasons that ___________________________________________________[Set Forth Reasons]. Dated: ____________________
________________________________
Print Name [Petitioner/Respondent]
________________________________
Signature
________________________________
Address
Motion for Extension of Time to File Brief / Form 9(a) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Motion for Extension of Time to File Brief in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: __________________________________
__________________________________ [Petitioner/Respondent]
Motion for Extension of Time to File Brief / Form 9(b) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. __ CA-IC _______________ ICA No. ___________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
MOTION FOR EXTENSION OF TIME TO FILE BRIEF
APPLICANT Respondent
_______________________ [Petitioner/Respondent] requests an extension of time
within which to file ________________ [his/hers] __________________ [Opening/ Answering/Reply] brief from _______________________ [Date Currently Due] to _____________________ [New Date] for the reasons that ___________________________________________________[Set Forth Reasons].
Dated: ____________________ ________________________________
Print Name [Petitioner/Respondent]
________________________________
Signature
________________________________
Address
Motion for Extension of Time to File Brief / Form 9(b) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Motion for Extension of Time to File Brief in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ____________________
__________________________________ [Petitioner/Respondent]
Stipulation for Extension of Time to File Brief / Form 10(a) – Page 1 of 3
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ___________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________
STIPULATION FOR EXTENSION OF TIME FOR FILE BRIEF
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent The undersigned stipulate and agree that ___________________
[Petitioner’s/Respondent’s] time for filing the ____________________ [Opening/ Answering/Reply] Brief in this matter may be extended from ________________________ [Current Due Date] to ___________________________ [New Date Desired]. This extension is requested because ______________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ ______________________________________________________________________ [List Reasons].
Dated: __________________
Stipulation for Extension of Time to File Brief / Form 10(a) – Page 2 of 3
_________________________________
_________________________________
Print Name [Petitioner/Respondent] __________________________ Signature __________________________ Address
Print Name [Petitioner/Respondent] _____________________________ Signature _____________________________ Address
Stipulation for Extension of Time to File Brief / Form 10(a) – Page 3 of 3
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Stipulation for Extension of time for File Brief in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _______________
__________________________________
[Petitioner/Respondent]
Stipulation for Extension of Time to File Brief / Form 10(b) – Page 1 of 3
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ___________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
STIPULATION FOR EXTENSION OF TIME FOR FILE BRIEF
APPLICANT Respondent The undersigned stipulate and agree that ___________________ [Petitioner’s/ Respondent’s] time for filing the ____________________ [Opening/ Answering/Reply] Brief in this matter may be extended from ________________________ [Current Due Date] to ___________________________ [New Date Desired]. This extension is requested because ____________________________________________________________
___________________________________________________________________________________ ______________________________________________________________________ [List Reasons].
Dated: __________________
Stipulation for Extension of Time to File Brief / Form 10(b) – Page 2 of 3
_________________________________
________________________________
Print Name [Petitioner/Respondent] ____________________________ Signature ____________________________ Address
Print Name [Petitioner/Respondent] _____________________________ Signature _____________________________ Address
Stipulation for Extension of Time to File Brief / Form 10(b) – Page 3 of 3
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and four (4) copies of the Stipulation for Extension of time for File Brief in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: __________________
__________________________________ [Petitioner/Respondent]
Request for Oral Argument / Form 11(a) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
No. ___ CA-IC ______________ ICA No. ____________________ Carrier No. _________________
REQUEST FOR ORAL ARGUMENT
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent Pursuant to ARCAP 18, the ________________ [Petitioner/Respondent] requests oral argument in the above-entitled matter. Dated: __________________
________________________________
Print Name [Petitioner/Respondent]
________________________________
Signature
________________________________
Address
Request for Oral Argument / Form 11(a) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the Request for Oral Argument in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ____________________
__________________________________ [Petitioner/Respondent]
Request for Oral Argument / Form 11(b) – Page 1 of 2
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ___________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
REQUEST FOR ORAL ARGUMENT
APPLICANT Respondent Pursuant to ARCAP 18, the ________________ [Petitioner/Respondent] requests oral argument in the above-entitled matter. Dated: __________________
_________________________________
Print Name [Petitioner/Respondent]
________________________________
Signature
________________________________
Address
Request for Oral Argument / Form 11(b) – Page 2 of 2
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the Request for Oral Argument in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _________________
__________________________________ [Petitioner/Respondent]
Statement of Costs / Form 12(a) – Page 1 of 3
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____ No. ___ CA-IC ______________ ICA No. ___________________ Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
__________________________________
APPLICANT,
Carrier No. _________________
STATEMENT OF COSTS
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent To: The Clerk of this Court and attorneys for the ____________ [Petitioner/Respondent]: The undersigned _________________ [Petitioner/Respondent] requests taxation of costs in the sum of $___________ [Dollar Amount] for the following expenses: 1. 2. 3. Clerk’s fees ...................................................................................... $_________ Briefs................................................................................................ $_________ [Other].............................................................................................. $_________ TOTAL ........................................................................................... $_________
_________________________________
Dated: __________________ Print Name [Petitioner/Respondent]
________________________________
Signature
________________________________
Address
Statement of Costs / Form 12(a) – Page 2 of 3
AFFIDAVIT SUPPORTING STATEMENT OF COSTS STATE OF ARIZONA ) ) ss. __________ COUNTY )
____________________________________ [Name], being first sworn upon oath, deposes and
says:
__________ [He/She] is the ______________ [Petitioner/Respondent] in this action, is better informed than the _______________ [Petitioner/Respondent] of the costs in this appeal. The
amounts listed above have actually been expended in connection with this case.
Print Name [Petitioner/Respondent]
__________________________________________________
Signature SUBSCRIBED AND SWORN TO before me on [Date]. [seal] Notary Public
Statement of Costs / Form 12(a) – Page 3 of 3
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the Statement of Costs in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: __________________
__________________________________ [Petitioner/Respondent]
Statement of Costs / Form 12(b) – Page 1 of 3
IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____ No. ___ CA-IC ______________ ICA No. ___________________ Carrier No. _________________
__________________________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
STATEMENT OF COSTS
APPLICANT Respondent To: The Clerk of this Court and attorneys for the ____________ [Petitioner/Respondent]: The undersigned _________________ [Petitioner/Respondent] requests taxation of costs in the sum of $___________ [Dollar Amount] for the following expenses: 1. 2. 3. Clerk’s fees ...................................................................................... $_________ Briefs................................................................................................ $_________ [Other].............................................................................................. $_________ TOTAL ........................................................................................... $_________
Dated: __________________ ________________________________ Print Name [Petitioner/Respondent] ________________________________ Signature ________________________________ Address
Statement of Costs / Form 12(b) – Page 2 of 3
AFFIDAVIT SUPPORTING STATEMENT OF COSTS STATE OF ARIZONA ) ) ss. __________ COUNTY ) ____________________________________ [Name], being first sworn upon oath, deposes and says: __________ [He/She] is the ______________ [Petitioner/Respondent] in this action, is better informed than the _______________ [Petitioner/Respondent] of the costs in this appeal. The amounts listed above have actually been expended in connection with this case.
[Signed] SUBSCRIBED AND SWORN TO before me on [Date]. [seal] Notary Public
Copy of the foregoing was mailed on _____________ [Date] to ____________________________ Name ____________________________ Address
Statement of Costs / Form 12(b) – Page 3 of 3
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and six (6) copies of the Statement of Costs in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _____________________
__________________________________ [Petitioner/Respondent]
Petition for Review / Form 13(a) – Page 1 of 8
[NOTE: LIMIT FOR THIS DOCUMENT IS 12 PAGES] IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ___________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
Carrier No. _________________
EMPLOYER Respondent _____________________________ INSURANCE CARRIER Respondent
PETITION FOR REVIEW
__________________________________
Print Name [Petitioner/Respondent] __________________________________ Signature __________________________________ Address
Petition for Review / Form 13(a) – Page 2 of 8
TABLE OF CONTENTS [page] Issues Presented for Review ................................................................................................ List of Additional Issues Presented to, but Not Decided by Court of Appeals and Which May Need to Be Decided if Review is Granted....................................................... Statement of Facts ............................................................................................................... Reasons for Granting this Petition ...................................................................................... Conclusion ........................................................................................................................... Certificate of Compliance ................................................................................................... Certificate of Service ...........................................................................................................
[Party filing the Petition for Review must attach a copy of the Court of Appeals decision to the Petition]
Petition for Review / Form 13(a) – Page 3 of 8
ISSUES PRESENTED FOR REVIEW (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(a) – Page 4 of 8
LIST OF ADDITIONAL ISSUES PRESENTED TO, BUT NOT DECIDED BY COURT OF APPEALS AND WHICH MAY NEED TO BE DECIDED IF REVIEW IS GRANTED (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(a) – Page 5 of 8
STATEMENT OF FACTS (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(a) – Page 6 of 8
REASONS FOR GRANTING THIS PETITION (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(a) – Page 7 of 8
CONCLUSION
[Date]
_________________________________________ [Print Name] [Petitioner/Respondent] _________________________________________ [Signature]
_________________________________________ [Address]
Petition for Review / Form 13(a) - Page 8 of 8
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and seven (7) copies of the Petition for Review in the Court of Appeals; and mailed a copy to the following parties:
________________________________________
[Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _____________________
__________________________________ [Petitioner/Respondent]
Petition for Review / Form 13(b) – Page 1 of 8
[NOTE: LIMIT FOR THIS DOCUMENT IS 12 PAGES] IN THE COURT OF APPEALS STATE OF ARIZONA DIVISION ____
__________________________________
No. ___ CA-IC ______________ ICA No. ___________________ Carrier No. _________________
EMPLOYER Petitioner,
__________________________________
INSURANCE CARRIER Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
APPLICANT Respondent
PETITION FOR REVIEW
_______________________________________
Print Name [Petitioner/Respondent] __________________________________ Signature __________________________________ Address
Petition for Review / Form 13(b) – Page 2 of 8
TABLE OF CONTENTS [page] Issues Presented for Review ................................................................................................ List of Additional Issues Presented to, but Not Decided by Court of Appeals and Which May Need to Be Decided if Review is Granted....................................................... Statement of Facts ............................................................................................................... Reasons for Granting this Petition ...................................................................................... Conclusion ........................................................................................................................... Certificate of Compliance ................................................................................................... Certificate of Service ...........................................................................................................
[Party filing the Petition for Review must attach a copy of the Court of Appeals decision to the Petition]
Petition for Review / Form 13(b) – Page 3 of 8
ISSUES PRESENTED FOR REVIEW (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(b) – Page 4 of 8
LIST OF ADDITIONAL ISSUES PRESENTED TO, BUT NOT DECIDED BY COURT OF APPEALS AND WHICH MAY NEED TO BE DECIDED IF REVIEW IS GRANTED (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(b) – Page 5 of 8
STATEMENT OF FACTS (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(b) – Page 6 of 8
REASONS FOR GRANTING THIS PETITION (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 13(b) – Page 7 of 8
CONCLUSION
[Date]
_________________________________________ [Print Name] [Petitioner/Respondent] _________________________________________ [Signature]
_________________________________________ [Address]
Petition for Review / Form 13(b) - Page 8 of 8
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and seven (7) copies of the Petition for Review in the Court of Appeals; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _____________________
__________________________________ [Petitioner/Respondent]
Petition for Review / Form 14(a) – Page 1 of 8
[NOTE: LIMIT FOR THIS DOCUMENT IS 12 PAGES] ARIZONA SUPREME COURT
No. ___ CA-IC ______________
__________________________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
ICA No. ____________________ Carrier No. _________________
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent
RESPONSE TO PETITION FOR REVIEW
_______________________________________
Print Name [Petitioner/Respondent] __________________________________ Signature __________________________________ Address
Petition for Review / Form 14(a) – Page 2 of 8
TABLE OF CONTENTS [page] Issues Presented for Review ................................................................................................ List of Additional Issues Presented to, but Not Decided by Court of Appeals and Which May Need to Be Decided if Review is Granted....................................................... Statement of Facts ............................................................................................................... Reasons for Granting this Petition ...................................................................................... Conclusion ........................................................................................................................... Certificate of Service ...........................................................................................................
[Party filing the Petition for Review must attach a copy of the Court of Appeals decision to the Petition]
Petition for Review / Form 14(a) – Page 3 of 8
ISSUES PRESENTED FOR REVIEW (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(a) – Page 4 of 8
LIST OF ADDITIONAL ISSUES PRESENTED TO, BUT NOT DECIDED BY COURT OF APPEALS AND WHICH MAY NEED TO BE DECIDED IF REVIEW IS GRANTED (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(a) – Page 5 of 8
STATEMENT OF FACTS (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(a) – Page 6 of 8
REASONS FOR GRANTING THIS PETITION (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(a) – Page 7 of 8
CONCLUSION
[Date]
_________________________________________ [Print Name] [Petitioner/Respondent] _________________________________________ [Signature]
_________________________________________ [Address]
Petition for Review / Form 14(a) - Page 8 of 8
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and seven (7) copies of the Response to Petition for Review in the Arizona Supreme Court; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: ____________________
__________________________________ [Petitioner/Respondent]
Petition for Review / Form 14(b) – Page 1 of 8
[NOTE: LIMIT FOR THIS DOCUMENT IS 12 PAGES] ARIZONA SUPREME COURT
No. ___ CA-IC ______________
__________________________________
APPLICANT, Petitioner, v. THE INDUSTRIAL COMMISSION OF ARIZONA, Respondent,
__________________________________
ICA No. ____________________ Carrier No. ____________________
EMPLOYER Respondent
__________________________________
INSURANCE CARRIER Respondent RESPONSE TO PETITION FOR REVIEW
__________________________________
Print Name [Petitioner/Respondent]
__________________________________
Signature
__________________________________
Address
Petition for Review / Form 14(b) – Page 2 of 8
TABLE OF CONTENTS [page] Issues Presented for Review ................................................................................................ List of Additional Issues Presented to, but Not Decided by Court of Appeals and Which May Need to Be Decided if Review is Granted....................................................... Statement of Facts ............................................................................................................... Reasons for Granting this Petition ...................................................................................... Conclusion ........................................................................................................................... Certificate of Service ...........................................................................................................
[Party filing the Petition for Review must attach a copy of the Court of Appeals decision to the Petition]
Petition for Review / Form 14(b) – Page 3 of 8
ISSUES PRESENTED FOR REVIEW (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(b) – Page 4 of 8
LIST OF ADDITIONAL ISSUES PRESENTED TO, BUT NOT DECIDED BY COURT OF APPEALS AND WHICH MAY NEED TO BE DECIDED IF REVIEW IS GRANTED (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(b) – Page 5 of 8
STATEMENT OF FACTS (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(b) – Page 6 of 8
REASONS FOR GRANTING THIS PETITION (*Add additional sheets of paper as necessary to complete this section)
Petition for Review / Form 14(b) – Page 7 of 8
CONCLUSION
[Date]
_________________________________________ [Print Name] [Petitioner/Respondent] _________________________________________ [Signature]
_________________________________________ [Address]
Petition for Review / Form 14(b) - Page 8 of 8
PROOF OF SERVICE
The undersigned _____________________________ [Petitioner/Respondent] on the ____ day of ___________, 200___, filed an Original and seven (7) copies of the Response to Petition for Review in the Arizona Supreme Court; and mailed a copy to the following parties:
________________________________________ [Petitioner/Respondent or Counsel] ________________________________________ Address ________________________________________ City, State, Zip Code
________________________________________ Industrial Commission of Arizona ________________________________________ Address ________________________________________ City, State, Zip Code
Dated: _______________
__________________________________ [Petitioner/Respondent]