Free Administrative Appeals Docketing Statement - West Virginia

Administrative Appeal Docketing Statement Instructions: 1. An administrative appeal docketing statement must be filed for every administrative agency case appealed to the circuit courts of West Virginia. The party filing the appeal may attach a more substantive petition or brief, but the administrative appeal docketing statement must be filed and filled out completely. The completed administrative appeal docketing statement must be served upon all parties to the agency proceeding, including those parties not represented by counsel, the agency itself, and the Attorney General's Office. The administrative appeal docketing statement must be in the form approved by the Supreme Court of Appeals or in a substantially similar format. Only one administrative appeal docketing statement shall be filed for each petition for appeal. If more than one party joins in a petition for appeal, they must select one party who is responsible for filing the administrative appeal docketing statement. The administrative appeal docketing statement should briefly address all of the points or issues to be raised in the appeal. However, it is not the appropriate document for making arguments or motions. A supporting petition may be filed with the administrative appeal docketing statement for such purposes. Conclusory statements, such as "The decision of the agency is not supported by the law or the facts", are unacceptable. While every effort should be made to include in the administrative appeal docketing statement all issues to be presented to the circuit court, the omission of an issue from the statement will not affect the jurisdiction of the circuit court to consider all issues presented by the appeal. If another party to the proceeding believes that the administrative appeal docketing statement is inaccurate or incomplete, that issue should be addressed in the response to the petition for appeal."

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ADMINISTRATIVE APPEALS DOCKETING STATEMENT Style of case (use from agency final order including case number): Agency: TIMELINESS OF APPEAL Date of entry of order appealed from: Date of filing of petition for appeal: VENUE: If appeal is not filed in Kanawha County, do you reside in or do business in this County? Yes No If so, provide the street address and telephone number for your residence or business in this County. If not, explain your reason(s) for filing this appeal outside of Kanawha County.

FINALITY OF ADMINISTRATIVE ORDER Is the order appealed from a final decision on the merits as to all issues and parties? Yes If not, what type of order are you appealing? CASE INFORMATION State briefly the nature of the case, the relief sought and the outcome at the agency. (Attach an additional sheet if necessary). Does the agency decision contain factual (evidentiary errors)? Yes No No

If so, please list the evidentiary errors briefly. (Attach an additional sheet if necessary).

Does the agency order contain legal errors (errors of law)? Yes No

If so, please list the errors of law briefly. (Attach an additional sheet if necessary).

CASE MANAGEMENT INFORMATION Name of Party filing this appeal (Petitioner):

Do you wish to make an oral presentation to the court? Yes No

List counsel for each party to the case at the agency. If a party is not represented by counsel, provide the requested information for that party. Include name, firm name, address and telephone number. (Attach an additional sheet if necessary).

Name of attorney or individual filing this Administrative Appeals Docketing Statement: Attorney Non-Attorney (self represented) No

Will you be handling the appeal?

Yes

If yes, provide name, firm name address and telephone number.

If there are multiple Petitioners add their names on an additional sheet, accompanied by a certification that all Petitioners concur in this filing. Signature:__________________________ WV Bar Number.____________________ Date:______________________________

Remember to attach: 1. Additional pages, if any, containing extended answers to questions on this form. 2. A copy of the agency final order or decision from which the appeal is taken. 3. A certificate of service, verifying that you have served this Administrative Appeals Docketing Statement upon all of the parties to the agency proceeding, the agency itself and the Attorney General's Office.