MINNESOTA COURT RULES

APPELLATE PROCEDURE

Forms provided here are for reference purposes. To download forms to fill out please visit the Minnesota Courts website.

FORM 116A - PETITION FOR WRIT OF CERTIORARI

STATE OF MINNESOTA

IN SUPREME COURT

CASE TITLE:
Employee-	PETITION FOR WRIT
Relator,	OF CERTIORARI
vs.	SUPREME COURT NUMBER:
Employer-	WORKERS' COMPENSATION
Respondent,	COURT OF APPEALS NUMBER:
Insurer-	DATE OF SERVICE OF WRITTEN
Respondent.	NOTICE OF DECISION:

TO:	The Supreme Court of the State of Minnesota:

The above-named relator hereby petitions the Supreme Court for a Writ of Certiorari to review a decision of the Workers' Compensation Court of Appeals, upon the grounds that it is not in conformity with the terms of the Workers' Compensation Act and is unwarranted by the evidence.

DATED:

NAME, ADDRESS, ZIP CODE, TELEPHONE NUMBER, AND ATTORNEY REGISTRATION LICENSE NUMBER OF ATTORNEY(S) FOR EMPLOYEE-RELATOR:

_

SIGNATURE

(The procedure for obtaining a writ of certiorari from the Supreme Court is set forth in RCAP 116. The rule prescribes the subject matter of writs in the Supreme Court, contents of the petition, bond or security, filing and fees, and requirements for service. Two copies of a completed statement of the case must accompany the petition.)

(Amended effective for appeals taken on or after January 1, 1992.)