     FILED
   Aug 10, 2018
   11:18 AM(CT)
 TENNESSEE COURT OF
WORKERS' COMPENSATION
       CLAIMS
                           Expedited Hearing Order Right to Appeal:

     If you disagree with this Expedited Hearing Order, you may appeal to the Workers’
Compensation Appeals Board. To appeal an expedited hearing order, you must:

   1. Complete the enclosed form entitled: “Expedited Hearing Notice of Appeal,” and file the
      form with the Clerk of the Court of Workers’ Compensation Claims within seven
      business days of the date the expedited hearing order was filed. When filing the Notice
      of Appeal, you must serve a copy upon all parties.

   2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten
      calendar days after filing of the Notice of Appeal. Payments can be made in-person at
      any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the
      alternative, you may file an Affidavit of Indigency (form available on the Bureau’s
      website or any Bureau office) seeking a waiver of the fee. You must file the fully-
      completed Affidavit of Indigency within ten calendar days of filing the Notice of
      Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will
      result in dismissal of the appeal.

   3. You bear the responsibility of ensuring a complete record on appeal. You may request
      from the court clerk the audio recording of the hearing for a $25.00 fee. If a transcript of
      the proceedings is to be filed, a licensed court reporter must prepare the transcript and file
      it with the court clerk within ten business days of the filing the Notice of
      Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both
      parties within ten business days of the filing of the Notice of Appeal. The statement of
      the evidence must convey a complete and accurate account of the hearing. The Workers’
      Compensation Judge must approve the statement before the record is submitted to the
      Appeals Board. If the Appeals Board is called upon to review testimony or other proof
      concerning factual matters, the absence of a transcript or statement of the evidence can be
      a significant obstacle to meaningful appellate review.

   4. If you wish to file a position statement, you must file it with the court clerk within ten
      business days after the deadline to file a transcript or statement of the evidence. The
      party opposing the appeal may file a response with the court clerk within ten business
      days after you file your position statement. All position statements should include: (1) a
      statement summarizing the facts of the case from the evidence admitted during the
      expedited hearing; (2) a statement summarizing the disposition of the case as a result of
      the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an
      argument, citing appropriate statutes, case law, or other authority.




For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
  Filed Date Stamp Here                     EXPEDITED HEARING NOTICE OF APPEAL                        Docket #: _______________________
                                                 Tennessee Division of Workers’ Compensation
                                                     www.tn.gov/labor-wfd/wcomp.shtml                 State File #/YR: __________________
                                                            wc.courtclerk@tn.gov
                                                               1-800-332-2667                         RFA #: __________________________
                                                                                                      Date of Injury: ___________________
                                                                                                      SSN: ___________________________




                   Employee


                   Employer and Carrier
          Notice
          Notice is given that
                                   [List name(s) of all appealing party(ies) on separate sheet if necessary]

          appeals the order(s) of the Court of Workers’ Compensation Claims at ______

                                                                 to the Workers’ Compensation Appeals Board.
           [List the date(s) the order(s) was filed in the court clerk’s office]

          Judge

          Statement of the Issues
          Provide a short and plain statement of the issues on appeal or basis for relief on appeal:




          Additional Information
          Type of Case [Check the most appropriate item]

                           ☐ Temporary disability benefits
                           ☐ Medical benefits for current injury
                           ☐ Medical benefits under prior order issued by the Court
          List of Parties
          Appellant (Requesting Party):                          ___At Hearing: ☐Employer ☐Employee
          Address:
          Party’s Phone:                                                     Email:
          Attorney’s Name:                                                                       BPR#:
          Attorney’s Address:                                                                            Phone:
          Attorney’s City, State & Zip code:
          Attorney’s Email:
                                       * Attach an additional sheet for each additional Appellant *

LB-1099     rev.4/15                                      Page 1 of 2                                                          RDA 11082
Employee Name: ____________________________________   SF#: ________________________________ DOI: __________________




Appellee(s)
Appellee (Opposing Party):____________________At Hearing: ☐Employer ☐Employee


Appellee’s Address:                                                                              ____
Appellee’s Phone:                                                   Email:                                ____
Attorney’s Name:                                                                     BPR#:                            _
Attorney’s Address:                                                                   Phone:                          _
Attorney’s City, State & Zip code: __________________                                        _________       ______
Attorney’s Email:                                                                                                     _
                         * Attach an additional sheet for each additional Appellee *



CERTIFICATE OF SERVICE

I,                                            , certify that I have forwarded a true and exact copy of this
Expedited Hearing Notice of Appeal by First Class, United States Mail, postage prepaid, to all parties
and/or their attorneys in this case in accordance with Rule 0800-02-22.01(2) of the Tennessee Rules of
Board of Workers’ Compensation Appeals on this the          ___day of       , 20__.



[Signature of appellant or attorney for appellant]



LB-1099   rev.4/15                                    Page 2 of 2                                   RDA 11082
                               Tennessee Bureau of Workers’ Compensation
                                      220 French Landing Drive, I-B
                                        Nashville, TN 37243-1002
                                              800-332-2667

                                          AFFIDAVIT OF INDIGENCY

I, ________________________________________, having been duly sworn according to law, make oath that
because of my poverty, I am unable to bear the costs of this appeal and request that the filing fee to appeal be
waived. The following facts support my poverty.

1. Full Name:                                            2. Address:

3. Telephone Number:                                     4. Date of Birth:

5. Names and Ages of All Dependents:

        ______________________________________ Relationship:

        ______________________________________ Relationship:

        ______________________________________ Relationship:

        ______________________________________ Relationship:

6. I am employed by:

        My employer’s address is:

        My employer’s phone number is:

7. My present monthly household income, after federal income and social security taxes are deducted, is:

$ ___________________

8. I receive or expect to receive money from the following sources:

        AFDC            $ ________ per month             beginning
        SSI             $ ________ per month             beginning
        Retirement      $ ________ per month             beginning
        Disability      $ ________ per month             beginning
        Unemployment $ ________ per month                beginning
        Worker’s Comp.$ ________ per month               beginning
        Other           $ ________ per month             beginning



LB-1108 (REV 11/15)                                                                               RDA 11082
9. My expenses are:

        Rent/House Payment $ ________ per month          Medical/Dental $ ___________ per month

        Groceries       $ ________ per month             Telephone       $            per month
        Electricity     $ ________ per month             School Supplies $            per month
        Water           $ ________ per month             Clothing        $            per month
        Gas             $ ________ per month             Child Care      $            per month
        Transportation $ ________ per month              Child Support   $            per month
        Car             $_________ per month
        Other           $ _______ per month (describe:                                      )


10. Assets:

        Automobile              $                        (FMV)
        Checking/Savings Acct. $
        House                   $                        (FMV)
        Other                   $                        Describe:

11. My debts are:

        Amount Owed                     To Whom




I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete
and that I am financially unable to pay the costs of this appeal.



                                                                         _

APPELLANT



Sworn and subscribed before me, a notary public, this

_______ day of                                    , 20_______.



NOTARY PUBLIC

My Commission Expires:




LB-1108 (REV 11/15)                                                                             RDA 11082
