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Here is the text we could read:

I appeal the

CLAIM OF APPEAL

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.

I request that the county clerk send a certified copy of the record to the

Circuit Court.

Circuit court number or name of county

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).

/s/
Appellant/Attorney signature

REQUEST FOR CERTIFIED RECORD

CERTIFICATE OF MAILING

/s/
Signature

Date

Approved, SCAOOriginal - Court1st copy - Appellee2nd copy - Appellant3rd copy - County Clerk4th copy - ReturnAdditional copies as neededCourt telephone no.Court addressAppellant’s name, address, and telephone no.Appellant’s attorney, bar no., address, and telephone no.Appellee’s name, address, and telephone no.vSTATE OF MICHIGANJUDICIAL CIRCUITCOUNTYCLAIM OF APPEAL ON APPLICATION FOR CONCEALED PISTOL LICENSE CASE NO.CC 79 (6/18) CLAIM OF APPEAL ON APPLICATION FOR CONCEALED PISTOL LICENSEMCL 28.425d, MCL 28.428, MCR 7.121Note: This appeal must be filed within 21 days of entry of the decision being appealed.

CC 79, Claim of Appeal on Application for Concealed Pistol License

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/appeals (2023-03)
Page(s): 1
Fields(s): 22
Average fields per page: 22
Reading Level: Grade 11
LIST Grouping(s): CO-07-00-00-00, CO-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

stat_e_f_n_l_county was STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY (0.59 conf)
cas_e was CASE NO (0.47 conf)
appellants_name_address was Appellants name address and telephone no (0.40 conf)
name_address_telephone was Appellees name address and telephone no (0.37 conf)
appellants_attorney_address was Appellants attorney bar no address and telephone no (0.52 conf)
provided_county_mc was a statement of statutory disqualification as provided by the county clerk under MCL 28425b11 because (0.45 conf)
b_failure_provide_receipt was b failure to provide a receipt under (0.38 conf)
failure_license_concealed_pistol was c failure of the county clerk to issue or reinstate a license to carry a concealed pistol (0.36 conf)
mc_l_b_county_clerk was MCL 28425b1 by the county clerk (0.43 conf)
mc_l_b was MCL 28425b9 by (0.47 conf)
mc_l was MCL 28425l3 by the (0.38 conf)
entity_failed_provide_receipt was Name of entity alleged to have failed to provide receipt (0.43 conf)
michigan_state_police was Michigan State Police (0.49 conf)
county_clerk was county clerk (0.45 conf)
signature_date__1 was Date (1.00 conf)
court_number_name_county was Circuit court number or name of county (0.39 conf)
signature_date__2 was Date_2 (1.00 conf)
text__1 was Text1 (0.35 conf)
text__2 was Text2 (0.35 conf)
text__3 was Text3 (0.35 conf)
text__4 was Text4 (0.35 conf)
text__5 was Text5 (0.35 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

CC 79, Claim of Appeal on Application for Concealed Pistol License

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02