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Here is the text we could read:

 

I am the 

[  ] Petitioner 
[  ] Attorney for the Petitioner and my Utah Bar number is _________ 

In the [  ]  Utah Supreme Court   [  ]  Utah Court of Appeals 

450 South State Street, Salt Lake City, UT 84111 

_____________________________________ 
Appellant     

Docketing Statement – Agency 
Review (URAP 9(e)) 

_______________________________ 
Appellate Court Case Number 

_____________________________________ 
Appellee 

______________________________ 

Agency Case Number 

(1) 

Nature of the review. This petition is to review the order of the 
____________________________________________________ (name of agency), 
which has the following effects (Briefly describe what the order does):  

  _

     

(2) 

Jurisdiction. This court has jurisdiction under: 

[  ] Utah Code Section 78A-3-102 (Supreme Court) 

[  ] Utah Code Section 78A-4-103 (Court of Appeals) 

[  ] Utah Code Section _____________ 

Docketing Statement – Agency Review 

Approved by the Board of Appellate Court Judges May 27, 2015 
Revised July 31, 2020 

Page 1 of 4 

ity, State, Zip 

 
Name 

ddress 

hone 

mail 

  A

  C

  P

  E

 

v. 

 

 

             

             

(3) 

Important dates.  

o  When was the final order of the agency entered? ________________ 

o  When was the Petition for Review filed? ________________  

(4) 

Issues on review. Separately describe the issue(s) that you plan to argue on 
review. 

 (5)  Summary of what happened in the agency. Briefly describe the facts relating 

to the issue(s) described above.  

(6) 

Related reviews. Have there been any petitions for review in this matter before 
this review? Are there any other reviews related to this review? 

[  ]  Yes    [  ]  No 

If yes to either question, provide the appellate court case numbers. If the earlier 
or related appeal resulted in a written decision, provide the decision citation, if 
available.  

 

Case Number 

Citation  (For example, 2015 UT 36 or 2015 UT App 103) 

 

 

Docketing Statement – Agency Review 

Approved by the Board of Appellate Court Judges May 27, 2015 
Revised July 31, 2020 

Page 2 of 4 

 

 

 

 

 

(7) 

Attachments.  

I have attached a copy of the final order I want the court to review 

If the review is of an order of the Public Service Commission, I have attached any 
application for rehearing filed under Utah Code Section 54-7-15. 

Sign here ► 

 

 

Typed or Printed Name 

o 

o 

 
Date 

 

Docketing Statement – Agency Review 

Approved by the Board of Appellate Court Judges May 27, 2015 
Revised July 31, 2020 

Page 3 of 4 

 

Certificate of Service 

I certify that on ____________________ (date) a copy of this Docketing Statement was 
served on all parties listed here by the method indicated below: 

Mailed  Emailed  Hand-delivered  Name 

  Mailing or Email Address 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

 

 

 

 

 

 

 

 

 

 

 

 

Date 

Typed or Printed Name 

Sign here ► 

 

 

Docketing Statement – Agency Review 

Approved by the Board of Appellate Court Judges May 27, 2015 
Revised July 31, 2020 

Page 4 of 4

Docketing Statement – Agency Review (URAP 9(e))

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah 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 legacy.utcourts.gov (2023-03)
Page(s): 4
Fields(s): 90
Average fields per page: 22
Reading Level: Grade 8
LIST Grouping(s): GO-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.

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

Docketing Statement – Agency Review (URAP 9(e))

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