Writ Of Certiorari (Workers Comp) {116B}

FORM 116B. WRIT OF CERTIORARI STATE OF MINNESOTA IN SUPREME COURT CASE TITLE: Employee Taxpayer, WRIT OF CERTIORARI APPELLATE COURT CASE NUMBER: [TO BE ADDED BY CLERK] vs. Employer Insurer Commissioner of Revenue. WORKERS' COMPENSATION COURT OF APPEALS [OR TAX COURT] NUMBER: DATE OF SERVICE OF WRITTEN NOTICE OF DECISION: [DATE OF FILING OF TAX COURT DECISION] TO: The Workers' Compensation Court of Appeals: You are hereby ordered to return to the Supreme Court within 30 days from this date the record, exhibits and proceedings in the above-entitled matter so that this court may review the decision of the Workers' Compensation Court of Appeals. Copies of this writ and accompanying petition shall be served forthwith either personally or by mail upon the Secretary of the Workers' Compensation Court of Appeals and upon the Employer-Respondent(s) above-named or their attorney(s) at: (address) Proof of service shall be filed with the clerk of the appellate courts. DATED: Clerk of Appellate Courts (Clerk's File Stamp) By: __________________________________ Assistant Clerk American LegalNet, Inc. www.FormsWorkFlow.com