Free STATE OF COLORADO - Colorado

STATE OF COLORADO
OFFICEthOF ADMINISTRATIVE COURTS
633 17 Street, Suite 1300, Denver, CO 80202 Fax: (303) 866-5909 1259 Lake Plaza Drive, Suite 230, Colo. Springs, CO 80906 Fax: (719) 576-5978 th 222 S. 6 Street, Suite 414, Grand Jct., CO 81501 Fax: (970) 248-7341

Claimant, COURT USE ONLY vs. Employer, and Respondent. PETITION TO REVIEW AND REQUEST FOR TRANSCRIPT (RULE 26 OACRP) WC NUMBER:

TO THE OFFICE OF ADMINISTRATIVE COURTS AND JUDGE _________________ : The ( claimant/ employer/ insurance carrier) petitions for review of the order of Judge _______________________ issued on _________________ (mo/day/yr). Petitioner objects to the Findings of Fact, Conclusions of Law, and Order of the Judge on the following ground(s):
(Set forth in detail the particular alleged errors and your objections to the order. You may attach additional pages):

The Petitioner request that a transcript(s) of the hearing be prepared and included as part of the record for the Petition to Review. Rule 26(D) OACRP. If requesting a partial transcript, also indicate the approximate ending time and description.
Date(s) of Hearing(s): Room and time the hearing began:

The Petitioner requests that the Office of Administrative Courts transmit the audio recording of the hearing to the following for preparation of the transcript. CHECK ONE of the following: (Note: The firms listed have indicated a willingness to prepare
transcripts at the per page rate set by the Colorado Supreme Court. The listing of a firm is not an endorsement by the Office of Administrative Courts) A/V Tronics, Inc., 600 17th Street, Suite 2800, Denver, CO 80202: (303) 634-2295; Agren Blando Court Reporting & Video, Inc., 216 16th Street, Suite 650, Denver, CO 80202: (303)296-0017 Federal Reporting Service, 17454 E. Asbury Place, Aurora, CO 80013: (303) 751-2777; Other court reporter or transcriptionist who does not have an interest in the case:

Name and Mailing Address:

Phone Number:

The Petitioner is indigent and has filed a Form #WC35, Application for Indigent Determination (Transcript), with the Division of Workers' Compensation.

CERTIFICATE OF SERVICE I hereby certify that a copy of this document has been mailed to the ALJ and to the following parties, at the addresses shown and on the date below:

ALJ: Office of Administrative Courts

Opposing Party or Attorney:

Mailed on the ______ day of ____________________, 20____.

Signature of Petitioner or Attorney

Petitioner's Name and Address (Printed)

Revised 01/13/09