Simply replace the unfilled areas such as "" and "[date]" with your information.
NOTICE OF APPEAL
In the matter of
[name of appellant]
APPEAL FROM REFEREE'S DECISION
Notice is hereby given that a decision was reached in the above referenced matter on the above date in the City of [city], State of [state/province], a copy of which is attached hereto and sets forth the particulars in this matter.
The appellant alleges that an error in decision has been made on the part of the referee and is appealing said decision on the following grounds: [grounds for appeal]