Approved, SCAO
Original - Court
1st copy - Appellee
2nd copy - Appellant
3rd copy - County Clerk
4th copy - Return
Additional copies as needed
Court telephone no.Court address
Appellant’s name, address, and telephone no.
Appellant’s attorney, bar no., address, and telephone no.
Appellee’s name, address, and telephone no.
v
STATE OF MICHIGAN
JUDICIAL CIRCUIT
COUNTY
CLAIM OF APPEAL ON APPLICATION
FOR CONCEALED PISTOL LICENSE
CASE NO.
CC 79 (6/18) CLAIM OF APPEAL ON APPLICATION FOR CONCEALED PISTOL LICENSE
MCL 28.425d, MCL 28.428,
MCR 7.121
Note: This appeal must be filed within 21 days of entry of
the decision being appealed.
1. I appeal the
a. statement of statutory disqualification as provided by the county clerk under MCL 28.425b(11) because:
(Specify the reasons on a separate sheet. Attach supporting documentation.)
b. failure to provide a receipt under
MCL 28.425b(1) by the county clerk.
MCL 28.425b(9) by
Name of entity alleged to have failed to provide receipt
.
MCL 28.425l(3) by the Michigan State Police. county clerk.
c. failure of the county clerk to issue or reinstate a license to carry a concealed pistol.
2. I am filing this appeal in the circuit court of the county in which I reside.
Date Appellant/Attorney signature
I request that the county clerk send a certified copy of the record to the
Circuit court number or name of county
Circuit Court.
I certify that on this date I served a copy of this claim of appeal on all parties and the county clerk by first-class mail addressed
to their last-known addresses as defined by MCR 2.107(C)(3).
Date Signature
CLAIM OF APPEAL
REQUEST FOR CERTIFIED RECORD
CERTIFICATE OF MAILING
/s/
/s/
