AGENCY'S LIST OF PARTIES & ATTORNEYS ON APPEAL Case Title Appeal Case No. Agency Name Name and Address of Party vs. Admin. Agency No. Hearing Officer Name and Address of Attorney of Record
CI
Date
Signature of Agency Representative Type or Print Name
Instructions: Send this list to the superior court where the appeal is filed. AP-311 (1/05)(cs) AGENCY'S LIST OF PARTIES AND ATTORNEYS ON APPEAL App. R. 602(d)(2)