NOTICE OF APPEAL
In the matter of
[name of appellant]
[address]
                 APPEAL FROM REFEREE'S DECISION

                      [number]     [date]

Notice is hereby given that a decision was reached in the
above referenced matter on the above date in the City of
            , State of             , a copy of which is
attached hereto and sets forth the particulars in this
matter.

That appellant alleges that an error in decision has been
made on the part of the referee and is appealing said
decision on the following grounds:  [grounds for appeal]

Date: ____________________
                               ___________________________
                                       [Signature]