Petition For Hearing Information Sheet

Request for Hearing - Tribal and Gaming Workers Compensation Dispute of Decision

USE OF THIS FORM

This form is designed to be used to file and commence an appeal disputing the decision of the San Manuel Band of Mission Indians Claims Administrator. 

DEFINITIONS 

Petitioner- is the party who is filing the appeal 

Agency or Administrative Agency is the Tribal Commission or agency having power under the Tribal law to make administrative decisions (Human Resources) 

Administrative Record means the agency’s record of the case on appeal 

Agency Decision means any final decision, order or determination of an Administrative Agency rendered on a particular issue 

Trial Court means the Trial Court of the San Manuel Tribal Court 

 

GENERAL INSTRUCTIONS 

Only those appeals authorized by Tribal Law shall be subject to review by the Trial Court. 

The Appeal should be typed or printed. The Appeal form must be filed, and once receiving a “File Stamp” by the Court Clerk the petitioner shall promptly serve a copy of the filed Notice of Appeal on the affected Agency and all other parties in person, by mail, or fax. Please see form Proof of Service – Civil POS-001 

 

COMPLETE THE APPEAL FORM AS FOLLOWS:

Page 1 of 1

Print your name and title, or if you are being represented by an attorney print the attorneys name and title. Print your residential address. Print your phone number This is the name of the agency (pre-printed on form) Print the date of the agency decision/or date of letter from agency Statement of Trial Court’s Jurisdiction (pre-printed on form) Print and describe a statement of facts describing the agency’s decision (what was the outcome in your own words; include a copy of the letter from agency and attach it to the notice of appeal form. Print and describe the relief you are seeking (what is the outcome you are requesting) Print and describe the reason you are appealing the agency decision

If more space is needed then what is provided in the boxes, please check the box on the bottom of page 1 of 1 to indicate an additional document is attached.

Page 2 of 2

You must sign and date the REQUEST FOR HEARING form. By signing, you are stating under penalty of perjury that the information that you have provided on form RFH-TWC 002 (Tribal Employee) or NOA-GWC 003 (Gaming Employee) is true and correct.  

Once this form is completed, provide it to the Court Clerk for submission of filing. Once the form had been reviewed and processed you will receive a case number. The Court Clerk will fill in the case number for you and file stamp the document. After receiving a file stamp on the “Notice of Appeal” form, the agency being appealed must be served a copy of the file stamped Notice of Appeal document. The individual serving the document cannot be a party to the action and must be over the age of 18 years old. Once service has been provided to the Agency, print and complete a Proof of Service (POS-001) form and file it with the Tribal Court Clerk.

Request for Accommodations

Contact the Court Clerk for accommodations for a language interpreter or assistance for persons with disabilities.