Opinion

RAYBURN, DAN v. CITY OF CAMDEN

  • 2026 TN WC 25
Court
Tennessee Court of Workers' Compensation Claims
Filed
Mar 19, 2026
Status
Published
On the bench
Durham
Cited by
0 cases
Authority
More cited than 39.3%

The opinion

FILED

Mar 19, 2026

01:21 PM(CT)

TENNESSEE COURT OF

WORKERS' COMPENSATION

CLAIMS

TENNESSEE BUREAU OF WORKERS’ COMPENSATION

IN THE COURT OF WORKERS’ COMPENSATION CLAIMS

AT JACKSON

DAN RAYBURN, ) Docket No.: 2024-70-5106

Employee, )

v. ) State File No.: 24193-2024

CITY OF CAMDEN, )

Employer, ) Judge Robert V. Durham

TN MUNICIPAL LEAGUE RISK )

MANAGEMENT, )

Insurer, )

and )

TROY HALEY, Administrator, )

Subsequent Injury and Vocational )

Recovery Fund.

COMPENSATION ORDER GRANTING BENEFITS

The Court held a Compensation Hearing on February 26, 2026, to determine

whether Mr. Rayburn suffered a compensable injury to his left hip, and if so, the

extent of his permanent vocational disability. The Court finds that Mr. Rayburn

proved he suffered a compensable injury and is entitled to extraordinary benefits

under section 50-6-242.

History of Claim

Mr. Rayburn was 62 when he suffered a fracture to his left hip on October 16,

2023, while pulling a barrel of waste oil up an incline using a two-wheel dolly. He

slipped and fell, and the dolly fell on him and pinned him to the pavement.

Emergency medical services took Mr. Rayburn to the hospital, where surgeons

repaired his hip.

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However, Mr. Rayburn’s hip fracture failed to heal, and in April 2024, he was

referred to Dr. Matthew Christie for further evaluation and treatment, which

ultimately led to a left hip replacement. Eventually, Dr. Christie placed him at

maximum medical improvement on February 3, 2025, and assigned an 11%

impairment. He also placed restrictions of no lifting more than 30 pounds, no

standing more than four to six hours per day, and no aerobic activities. Dr. Christie

later completed a form stating that Mr. Rayburn’s injury prevented him from

performing his regular job duties with Camden.

Dr. Christie last saw Mr. Rayburn in April 2025 for a one-year post-surgical

follow-up. Mr. Rayburn has not sought further treatment since.

In his deposition, Dr. Christie testified that Mr. Rayburn would not injure his

hip replacement with activity. But because he uses a cane, he would be incapable of

climbing a ladder or lifting heavy weights, or really “doing any sort of manual

labor.”

However, immediately after this testimony, he was asked to review a

functional capacity evaluation stating that Mr. Rayburn could not walk for more than

five or ten minutes, had to use rails to navigate stairs, and had difficulty putting on

his shoes and socks. The evaluation also said that he could sit in a chair for one

hour. Dr. Christie concluded that Mr. Rayburn’s function was based on his ability

to tolerate activities and that these limitations would be permanent.

On cross-examination, Dr. Christie was again asked about Mr. Rayburn’s

permanent restrictions. He said that according to his last work release, based on his

evaluation and treatment, his restrictions were no lifting over 30 pounds, limit

standing/walking to six hours a day, and no aerobic activity.

Dr. Christie was not asked about Mr. Rayburn’s current complaints of

complete numbness going down his left leg past his knee if he stayed in one position

for long or that he experienced uncontrolled incontinence when that happened. He

stated that he was not even aware of those complaints.

After Dr. Christie placed him at maximum medical improvement, Mr.

Rayburn met with Roger Pafford, mayor of Camden, to discuss work. Mr. Rayburn

did not feel he could do his previous job with the Streets Department, and Mr.

Pafford did not have any part-time or light-duty work. Although Mr. Pafford

testified that he would have liked to return Mr. Rayburn to work, he terminated his

employment. Mr. Rayburn has not worked since. His weekly compensation rate is

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$510.09.

Mr. Rayburn sought permanent total disability benefits or alternatively

additional extraordinary benefits under section 50-6-242(a)(2). To that end, he

submitted the following evidence.

He is currently 65 years old. He completed the ninth grade before dropping

out of high school. He worked for a few years at a factory before getting a job

delivering milk, which required him to drive a truck, unload and stock gallons of

milk, and do bookkeeping and sales. He did this for ten years before Camden hired

him for its Streets Department in the late 1990s.

Mr. Rayburn began as a laborer. His duties included picking up trash, stacking

and hauling brush, repairing potholes, and trimming trees. After a few years, he

became an operator. He drove and operated city vehicles, including bucket trucks,

backhoes, salt trucks, and graders but still performed many of the physical laborer

tasks.

Mr. Rayburn testified that over the years, he has had several medical

conditions that have limited his physical activities. He had a heart attack 15 years

ago. He suffered from a double hernia that was surgically repaired but did not lift

as much as before the surgery. He also had a work accident, where a log came

through the rear window of his truck and hit his head. The accident caused him to

suffer from vertigo, which prevented him from working on ladders or in the bucket

truck. However, Mr. Rayburn did not produce any medical records or doctor’s

opinions documenting these conditions or his asserted limitations.

Mr. Rayburn informed his supervisors of these conditions and limitations, but

except for his vertigo preventing him from working at a height, he worked his regular

job duties.

As for his current condition, Mr. Rayburn testified that he continues to suffer

from significant problems with his left hip and low back. He said that pain travels

across his low back and down his left leg. He cannot stand or sit for more than 15

or 20 minutes before he needs to switch positions. He testified that not only does he

suffer from pain, but after a few minutes of the same activity, his left leg becomes

completely numb from his hip to below the knee. He can only walk very short

distances without a cane. He said his numbness leads to uncontrolled urination.

While he drives his own vehicle and periodically travels to Nashville, he must

3

stop frequently. He cannot mow the lawn or work in his shop for more than an hour

before needing a break. He gave up hunting and fishing, and he no longer drives his

four-wheeler. He said he never gets a full night’s sleep due to his pain and urinates

five or six times a night.

He has not looked for work because he feels he cannot do manual labor and

he has no other skills. He knows very little about computers. Mr. Rayburn testified

that before his injury, he had intended on working to his full retirement age of 67,

but instead he filed for social security retirement benefits and received his first check

in January 2024. He receives $1,454.90 monthly.

Mr. Rayburn’s wife also testified as to his limitations. She said that he does

not engage in significant physical activity, such as yardwork or working in his shop,

without taking frequent breaks. He cannot walk for more than 45 minutes to an hour.

She confirmed that he has urinated on himself occasionally and has difficulty

sleeping. She said that if he drives to Nashville, he will take a break in the middle

of the trip.

Mr. Rayburn also testified about his accident. While the mechanics of Mr.

Rayburn’s injury were not disputed, Camden contested whether moving the oil was

in the course and scope of his employment.

On that issue, Mr. Rayburn explained that the department stored waste oil in

a large tank until it could be removed by an outside business. He said he often used

this waste oil to lubricate city machinery to protect against rust and aid in moving

frozen chains and hinges, and this was common practice for him and other

employees. On the date of injury, he was taking the used oil to one of the machines

to lubricate it when he fell. Mr. Rayburn admitted his supervisor, Kevin Johnson,

did not instruct him to use the oil, but Mr. Rayburn said department employees were

often left to perform tasks on their own initiative.

Mr. Rayburn admitted that he had planned to take some oil home with him at

some point for a personal project, and he “probably” would have done so on the day

of injury after he finished lubricating the machine. He said that employees often

took waste oil home for personal use, and no one ever objected.

Camden offered the testimony of several of its employees on this issue. Mr.

Rayburn’s coworkers testified that they heard him ask for some waste oil on the

morning of his accident. They said that they had never removed any waste oil from

the tank where it is kept and never used it to lubricate any machinery. One of them

4

said that before they began using the commercial cleaner they use now, he had used

a mixture of new oil and diesel on the machinery.

Mr. Johnson testified that he remembered Mr. Rayburn asking for a bucket to

put waste oil in, and he told him to ask the mechanic. He said that he has never used

waste oil to lubricate the machines, and if anyone asked, he would have advised

against it.

Findings of Fact and Conclusions of Law

Mr. Rayburn has the burden of proving the essential elements of his workers’

compensation claim by a preponderance of the evidence. Scott v. Integrity Staffing

Solutions, 2015 TN Wrk. Comp. App. Bd. LEXIS 24, at *6 (Aug. 18, 2015).

Causation

To be compensable, Mr. Rayburn’s injury must arise primarily out of and

within the course and scope of his employment. Tenn. Code Ann.§ 50-6-102(12).

Camden agreed that Mr. Rayburn’s hip fracture occurred at work, but it argued that

it did not primarily arise out of the performance of his duties and happened during a

purely personal errand.

Longstanding Tennessee law explains the difference between these two

requirements:

The phrase “arising out of” refers to cause or origin and “in the course

of” refers to time, place and circumstances. An injury arises out of the

employment when “there is a causal connection between the conditions

under which the work is required to be performed and the resulting

injury.”

Hubble v. Dyer Nursing Home, 188 S.W.3d 525, 534 (Tenn. 2006) (citations

omitted).

Here, Mr. Rayburn testified that he was transporting waste oil to lubricate and

protect department machinery and that he and other employees had done this several

times over the years. While no one told him to oil the machinery, he was often

expected to initiate work tasks. Although his coworkers and supervisor never used

waste oil on department machines, they did not contradict his testimony that he did.

5

Mr. Rayburn conceded that he would have taken some of the oil home with

him for personal use after he finished lubricating the machines. He said that he had

done it before and so had several other employees, and no one had ever told him not

to do so. Again, no one, including his supervisor. contradicted this testimony.

Further, they were all aware that he intended to get some waste oil, and no one

instructed him otherwise.

The Court finds a causal connection between Mr. Rayburn moving the oil to

maintain the machinery, principally for the benefit of the Street Department, and his

resulting slip, fall, and work injury. Mr. Rayburn established by a preponderance of

the evidence that he was performing his work duties when he fell and fractured his

hip. The fact that he intended to take at least some of the oil home with him was

incidental to his accident. Thus, the injuries he sustained were primarily caused by

his employment and are compensable.

Disability Benefits under section 50-6-207(3)(B)

The Court must now determine the extent of Mr. Rayburn’s permanent

disability and begins the analysis under section 50-6-207(3)(B). The undisputed

medical proof is that he sustained an 11% impairment from his work injury. This

entitles him to 49 weeks of benefits. The proof also established by a preponderance

of the evidence that he was unable to work at a job making at least his pre-injury

wage at the end of his compensation period on January 13, 2026. Thus, the original

award is multiplied by 1.35, and his “resulting award” is 66.5 weeks of benefits.

Given that Mr. Rayburn also proved he was over the age of 40 and did not

have a high school education, the resulting award is multiplied by 1.74, which is the

product of 1.45 and 1.2. Thus, the Court finds that the increased award owed to Mr.

Rayburn totals 115.71 weeks of benefits.

Permanent Total Disability

To receive permanent total disability benefits, Mr. Rayburn must prove under

Section 50-6-207(4)(B) that he suffered an injury that “totally incapacitates [him]

from working at an occupation that brings [him] an income.” In determining

whether he is totally disabled, the Court must focus on his “ability to return to gainful

employment.” Cleek v. Wal-Mart Stores, Inc., 19 S.W.3d 770, 774 (Tenn. 2000).

In Hubble, 188 S.W.3d at 535, the Supreme Court listed several factors relevant to

the question of total disability: “the employee’s skills, training, education, age, job

opportunities in the immediate and surrounding communities, and the availability of

6

work for an individual with that particular disability.”

The Court finds that Mr. Rayburn proved that he was unable to return to his

job with the Streets Department due to his work-related injury. Dr. Christie testified

that using a cane would prevent him from performing manual labor. Further, Mr.

Pafford testified Camden did not have light-duty work for him.

However, the question is not whether Mr. Rayburn’s restrictions from his

work injury prevent him from doing his old job. He must prove they totally

incapacitate him from working in the general labor market. For the following

reasons, the Court finds Mr. Rayburn did not submit sufficient evidence to meet this

burden.

First, Mr. Rayburn did not introduce an opinion from a vocational expert to

assess his vocational impairment based on factors set out in Hubble. Mr. Rayburn

maintained that the law allows the Court to determine he is totally disabled without

this opinion. Owens v. Sitters, Etc., 2023 TN Wrk. Comp. App. Bd. LEXIS 55, at

*23 (Nov. 17, 2023). While true, Mr. Rayburn offered no proof on job opportunities

in the immediate and surrounding communities, and the availability of work for an

individual with that particular disability.

Mr. Rayburn also provided little in the way of lay testimony as to his cognitive

and learning skills. He did not testify that he had difficulty learning, reading, doing

math, or acquiring new skills. His sole testimony in this regard was that he only had

jobs involving manual labor and knows little about computers.

Further, much of Mr. Rayburn’s asserted physical impairments stem from

symptoms that he did not confirm through medical proof. He testified about his

problems with vertigo and imbalance, but he did not submit any medical evidence

that he suffers from this condition, why it occurs, or how it affects his ability to work.

Mr. Rayburn also testified that he now has pain and numbness so he cannot

sit or stand for more than 15 minutes, and in fact, his numbness is so pervasive that

he experiences uncontrolled urination. However, Dr. Christie, the only medical

expert, did not attribute these symptoms to Mr. Rayburn’s injury and hip

replacement. In fact, he did not address them at all. In addition, Mr. Rayburn has

not sought treatment for these continued complaints; the last treatment he received

was in April 2025.

Dr. Christie’s testimony as to Mr. Rayburn’s restrictions was mainly linked to

7

the fact that he used a cane, which would get in the way of most manual labor

activities. He also said that Mr. Rayburn would not damage his hip through physical

activity.

In addition to expert opinion, the “employee’s own assessment of his or her

overall physical condition, including the ability or inability to return to gainful

employment, is competent testimony that must be considered” when determining

vocational disability. Hubble, 188 S.W.3d at 535-36. Mr. Rayburn testified that he

did not believe he could return to any of his past jobs.

Notably, Mr. Rayburn went further than that and testified that he did not

believe he could return to any gainful employment. This assertion is significantly

broader, and Mr. Rayburn’s evidence for it is lacking.

Given these factors, the Court finds that Mr. Rayburn has not proven by a

preponderance of the evidence that his work-related injury has made him

permanently and totally disabled.

Extraordinary Benefits under section 50-6-242

The next question is whether Mr. Rayburn is entitled to permanent disability

benefits under section 50-6-242. This statute provides that in “extraordinary” cases

he may receive up to 275 weeks of benefits. To do so, he must first satisfy the

elements of section 50-6-207(3)(B). The employee must prove by clear and

convincing evidence that limiting recovery to section 50-6-207(3)(B) would be

“inequitable in light of the totality of the circumstances.” Finally, if he does so, he

must then prove the following: 1) he has at least a 10% impairment rating; (2) the

authorized doctor signed a form certifying that he could not return to the pre-injury

occupation due to restrictions related to the work injury; (3) he is not earning at least

70% of the pre-injury wage.

As discussed above, Mr. Rayburn met the criteria for increased benefits under

50-6-207(3)(B). The evidence also confirmed that he meets the final three elements

set out above.

The question remains whether he proved by clear and convincing evidence

that limiting benefits to section 50-6-207(3)(B) would be inequitable under the

totality of the circumstances. .

The undisputed medical evidence was that he could no longer perform manual

8

labor. This evidence was confirmed by Mr. and Ms. Rayburn’s undisputed

testimony about Mr. Rayburn’s physical limitations. Given his age, lack of

education, and the fact that he has worked in manual labor jobs all his life, including

over 20 years in the same job, the Court finds Mr. Rayburn proved by clear and

convincing evidence that limiting him to the benefits owed under section 50-6-

207(3)(B) would be inequitable.

. The Court finds he is awards 225 weeks of benefits under section 50-6-242

based on the totality of the circumstances.

Social Security Offset

Tennessee Code Annotated section 50-6-207(4)(A)(i) provides that payments

of permanent disability benefits shall be reduced by the amount of any Social

Security Old Age benefits attributable to employer contributions. In McCoy v.

T.T.C. Ill., Inc., 14 S.W.3d 734, 737 (Tenn. 2000), the Supreme Court held that the

reduction applies to employees over age 60 who suffer injuries to the body as a whole

and are awarded either permanent total or permanent partial disability benefits. The

Court held the statute was intended to provide a 50% offset of the total amount of

Social Security Old Age benefits received by the employee. Id. at 738.

Mr. Rayburn argued that before his injury, he intended to work until age 67,

when he would have been eligible for full retirement benefits. However, when he

became unable to work, he was forced to take early retirement benefits at a reduced

rate. Thus, he contended that the offset does not apply to his disability benefits

because he is not receiving the full retirement benefits he could have received had

he not been forced into retirement.

Although a novel argument, Mr. Rayburn did not cite any authority for this

position. The statute makes no distinction between reduced or full retirement

benefits. Thus, the Court rejects Mr. Rayburn’s contention and finds that Camden

is entitled to the full offset.

Here, Mr. Rayburn receives $1,454.90 monthly in Social Security Old Age

benefits, which is equal to $335.75 per week. Fifty percent of those benefits is

$167.87. Mr. Rayburn’s weekly compensation rate is $510.09. So, after a reduction

of $167.87, his adjusted permanent partial disability weekly rate for benefits is

$342.22 and, at that adjusted rate, 225 weeks of permanent partial disability benefits

equals $76,999.50.

9

SIF Liability

Since Mr. Rayburn did not prove permanent total disability, the Subsequent

Injury Fund is not liable for any benefits. Id. § 50-6-208(a)(1).

IT IS, THEREFORE, ORDERED THAT:

1. Camden shall pay Mr. Rayburn a lump sum of $76,999.50 in permanent

partial disability benefits. Mr. Rayburn’s counsel is entitled to a 20% attorney

fee, which equals $15,399.90.

2. The Subsequent Injury and Vocational Recovery Fund is not liable.

3. Mr. Rayburn may file a motion to recover his discretionary costs.

4. Dr. Christie remains Mr. Rayburn’s treating physician for his work-related

injury. Camden shall pay for reasonable, necessary, and related medical

treatment for this injury.

5. Camden shall pay costs of $150.00 to the Court Clerk within five business

days of this order becoming final.

6. Camden shall file with the Court Clerk a Statistical Data Form within ten

business days of this order becoming final.

7. This Compensation Order is a final adjudication upon the merits of Mr.

Rayburn’s claim for benefits. Unless appealed, it shall become final in 30

days.

ENTERED on March 19, 2026.

_____________________________________

ROBERT DURHAM, JUDGE

Court of Workers’ Compensation Claims

10

APPENDIX

Exhibits:

1. Social Security benefit summary

2. Dr. Christie’s deposition

3. Medical records and medical bills

4. Medical records filed by the City of Camden

5. City of Camden’s Interrogatory Responses

6. Physician’s Certification Form

7. First Report of Injury

8. Camden’s Payment Summary

9. Mr. Rayburn’s Responses to Camden’s Interrogatories

10. Mr. Rayburn’s Responses to SIF’s Interrogatories

11. Separation Notice

12. Pictures of accident scene

13. Emergency Room record

11

CERTIFICATE OF SERVICE

I certify that a copy of the Order was sent as indicated on March 19, 2026.

Name Via Service sent to:

Email

Charles Hicks X Office@Hickslawfirm.net

Robert Binkley X RBinkley@raineykizer.com

Tim Kellum X Tim.kellum@tn.gov

____________________________________

PENNY SHRUM, Court Clerk

WC.CourtClerk@tn.gov

12

Right to Appeal:

If you disagree with the Court’s Order, you may appeal to the Workers’ Compensation

Appeals Board. To do so, you must:

1. Complete the enclosed form entitled “Notice of Appeal” and file it with the Clerk of the

Court of Workers’ Compensation Claims before the expiration of the deadline.

¾ If the order being appealed is “expedited” (also called “interlocutory”), or if the

order does not dispose of the case in its entirety, the notice of appeal must be filed

within seven (7) business days of the date the order was filed.

¾ If the order being appealed is a “Compensation Order,” or if it resolves all issues

in the case, the notice of appeal must be filed within thirty (30) calendar days of

the date the Compensation Order was filed.

When filing the Notice of Appeal, you must serve a copy on the opposing party (or attorney,

if represented).

2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten calendar

days after filing the Notice of Appeal. Payments can be made in-person at any Bureau office

or by U.S. mail, hand-delivery, or other delivery service. In the alternative, you may file an

Affidavit of Indigency (form available on the Bureau’s website or any Bureau office)

seeking a waiver of the filing fee. You must file the fully-completed Affidavit of Indigency

within ten calendar days of filing the Notice of Appeal. Failure to timely pay the filing

fee or file the Affidavit of Indigency will result in dismissal of your appeal.

3. You are responsible for ensuring a complete record is presented on appeal. If no court

reporter was present at the hearing, you may request from the Court Clerk the audio

recording of the hearing for a $25.00 fee. If you choose to submit a transcript as part of your

appeal, which the Appeals Board has emphasized is important for a meaningful review of

the case, a licensed court reporter must prepare the transcript, and you must file it with the

Court Clerk. The Court Clerk will prepare the record for submission to the Appeals Board,

and you will receive notice once it has been submitted. For deadlines related to the filing of

transcripts, statements of the evidence, and briefs on appeal, see the applicable rules on the

Bureau’s website at https://www.tn.gov/wcappealsboard. (Click the “Read Rules” button.)

4. After the Workers’ Compensation Judge approves the record and the Court Clerk transmits

it to the Appeals Board, a docketing notice will be sent to the parties.

If neither party timely files an appeal with the Appeals Board, the Court Order

becomes enforceable. See Tenn. Code Ann. § 50-6-239(d)(3) (expedited/interlocutory

orders) and Tenn. Code Ann. § 50-6-239(c)(7) (compensation orders).

For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.

NOTICE OF APPEAL

Tennessee Bureau of Workers’ Compensation

www.tn.gov/workforce/injuries-at-work/

wc.courtclerk@tn.gov | 1-800-332-2667

Docket No.: ________________________

State File No.: ______________________

Date of Injury: _____________________

___________________________________________________________________________

Employee

v.

___________________________________________________________________________

Employer

Notice is given that ____________________________________________________________________

[List name(s) of all appealing party(ies). Use separate sheet if necessary.]

appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the

Workers’ Compensation Appeals Board;ĐŚĞĐŬŽŶĞŽƌŵŽƌĞĂƉƉůŝĐĂďůĞďŽdžĞƐĂŶĚŝŶĐůƵĚĞƚŚĞĚĂƚĞĨŝůĞͲ

ƐƚĂŵƉĞĚŽŶƚŚĞĨŝƌƐƚƉĂŐĞŽĨƚŚĞŽƌĚĞƌ;ƐͿďĞŝŶŐĂƉƉĞĂůĞĚͿ͗

ප Expedited Hearing Order filed on _______________ ප Motion Order filed on ___________________

ප Compensation Order filed on__________________ ප Other Order filed on_____________________

issued by Judge _________________________________________________________________________.

Statement of the Issues on Appeal

Provide a short and plain statement of the issues on appeal or basis for relief on appeal:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Parties

Appellant(s) (Requesting Party): _________________________________________ ‫܆‬Employer ‫܆‬Employee

Address: ________________________________________________________ Phone: ___________________

Email: __________________________________________________________

Attorney’s Name: ______________________________________________ BPR#: _______________________

Attorney’s Email: ______________________________________________ Phone: _______________________

Attorney’s Address: _________________________________________________________________________

* Attach an additional sheet for each additional Appellant *

LB-1099 rev. 01/20 Page 1 of 2 RDA 11082

Employee Name: _______________________________________ Docket No.: _____________________ Date of Inj.: _______________

Appellee(s) (Opposing Party): ___________________________________________ ‫܆‬Employer ‫܆‬Employee

Appellee’s Address: ______________________________________________ Phone: ____________________

Email: _________________________________________________________

Attorney’s Name: _____________________________________________ BPR#: ________________________

Attorney’s Email: _____________________________________________ Phone: _______________________

Attorney’s Address: _________________________________________________________________________

* Attach an additional sheet for each additional Appellee *

CERTIFICATE OF SERVICE

I, _____________________________________________________________, certify that I have forwarded a

true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described

in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this

case on this the __________ day of ___________________________________, 20 ____.

______________________________________________

[Signature of appellant or attorney for appellant]

LB-1099 rev. 01/20 Page 2 of 2 RDA 11082

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.

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