[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]

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