PETITION FOR APPEAL 
TO THE BOARD 
 
 
An appeal is hereby made from the Administrator’s decision in accordance with Rule 715-12 of 
the Rules and Regulations for Appeals to the Government Employees’ Retirement System’s 
Board of Trustees. 
 
 
I. 
Name of Appellant: ________________________________________________ 
II. 
Appellant’s Address: _______________________________________________ 
     _______________________________________________ 
III. 
Legal Representative (if any): 
(a) Name: _____________________________________________________ 
(b) Address: ____________________________________________________ 
         ____________________________________________________ 
(c) Telephone No: _______________________________________________ 
IV. 
State the decision or action below from which an appeal is being taken: (Please attach 
a copy of the Decision) 
 
V. 
Issues present for review by the Board. 
 
 
 
 
VI. 
Statement of the case: Describe the nature of the case, the course of proceedings and 
its disposition below: 
 
 
 
 
 
 
 
Petition for Appeal 
to the Board of Trustees 
 
 
 
 
VII. 
Statement of the Facts: Facts which are relevant to the issue presented for review, 
with appropriate references to the record. 
 
 
 
 
 
 
 
 
VIII. Argument: Set forth Appellant’s contentions with respect to the issues, with citations 
to the authorities and parts of the record relied on. 
 
 
 
 
 
 
 
IX. 
Statement of the Relief sought: 
 
 
 
 
 
 
Dated: ______________ 
 
 
 
____________________________________ 
 
 
 
 
 
 
 
 
Signature of Appellant