Form 67-Confirmation of Notice of Appeal

Form 67.

O.18, r.2

(heading as in Form 1 or Form 3)

CONFIRMATION OF NOTICE OF APPEAL

The above-named appellant hereby confirms the notice of appeal given by him against a decision of a Local Court.

1. The decision appealed against is the (decision/order/sentence) of the Local Court held at . . . (place) given on . . . (date) whereby (set out).

2. Notice of appeal was lodged with the Registrar by radiogram on the . . . day of . .

3. The appellant appeals against the whole of the decision (that part of the decision whereby (set out)).

4. The grounds relied on in support of the appeal are (set out).

5. The order which the appellant seeks in lieu of the decision appealed from is (set out).

6. The full names and addresses of the appellant and respondent respectively are:

(a) . . . (name and address) Appellant

(b) . . . (name and address) Respondent

Dated the . . . day of . . . 20...

Appellant or

Appellant's Solicitor(s)