Approved,  SCAO

STATE OF MICHIGAN

Original - Circuit court
1st  copy  -  District  court/agency

2nd copy - Appellee
3rd copy - Appellant

CASE NO.

JUDICIAL CIRCUIT
COUNTY

APPLICATION FOR LEAVE
TO APPEAL

Court  address

Plaintiff's name, address, and telephone no.

Defendant's name, address, and telephone no.

Appellant
Appellee

v

Court  telephone  no.

Appellant
Appellee

Plaintiff's attorney, bar no., address, and telephone no.

Defendant's attorney, bar no., address, and telephone no.

1. I,

Name

Date

    in the

         by

Court name and number or agency

Name of judge

The nature of the judgment/order/decision being appealed is

Bar no.

.

 .

      ,  request leave to appeal a judgment/order/decision entered on

2.

No appeal of right exists.
The time for taking an appeal under MCR 7.105(A) has expired.
An appeal of right exists, but waiting to appeal of right would not be an adequate remedy.

3. This application for leave is being filed

a. within the time required by MCR 7.105(A).
b. after, but not more than 6 months after, entry of the judgment/order/decision appealed pursuant to MCR 7.105(A).
(If the application is filed under 3.b, a statement of facts explaining the delay must be attached.)
c. because an appeal of right from an agency's order or decision was not timely filed and statute authorizes a late appeal.

4. I allege the following errors. (Attach additional pages as needed.)

5. I request the following relief. (Attach additional pages as needed.)

6. The following is my position supporting each issue, as required by MCR 7.212(C). (Attach additional pages as needed.)

7. This is an interlocutory appeal. I will suffer substantial harm by awaiting final judgment before taking an appeal because:

(Attach  additional  pages  as  needed.)

Date

Date

/s/
Appellant  signature

CERTIFICATE OF MAILING

/s/
Signature

I certify that on this date I served a copy of this application for leave to appeal on the parties or their attorneys and on the trial court
or agency by first-class mail addressed to their last-known addresses as defined by MCR 2.107(C)(3).

CC 298   (6/12)   APPLICATION FOR LEAVE TO APPEAL

MCR 7.103(B), MCR 7.105