From [Your Address]
[The address on the Tribunal Service decision notice]
Date
Dear Sir/Madam
REQUEST FOR LEAVE TO APPEAL TO THE UPPER TRIBUNAL
NI No: [Your National Insurance Number]
Your Ref: [appeal reference]
Tribunal Hearing Date: [The date of the hearing]
I wish to seek permission to appeal the tribunal decision as above:
I think the tribunal made the following legal errors in this case:
[Give the reasons why you think the tribunal went wrong]
Yours faithfully
[Your signature]
[Your name]
[ A contact telephone number, if you have one]