The opinion
FILED
Apr 21, 2026
08:00 AM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT MURFREESBORO
KATHY GOAD, Docket No. 2023-05-7741
Employee,
v.
CAPSTONE LOGISTICS, LLC, State File No. 73552-2023
Employer,
and
XL INS. AMERICA, INC., Judge Dale Tipps
Carrier.
EXPEDITED HEARING ORDER GRANTING BENEFITS
The Court held an Expedited Hearing on April 14, 2026, on Ms. Goad’s
request for additional temporary disability and medical benefits. For the reasons
below, the Court holds she is likely to prevail at a final hearing that she is entitled to
continuing medical treatment, including the surgery ordered by Dr. John Burleson,
but not to temporary partial disability benefits.
Claim History
Ms. Goad was working for Capstone on September 27, 2023, when a
towmotor pushed a pallet into the back of her legs, causing her to fall backward and
land in a sitting position on some cardboard on the pallet. She reported back pain,
and Capstone sent her to an urgent care clinic that day.
The physician’s assistant at the clinic prescribed an anti-inflammatory and a
muscle relaxant and assigned light-duty restrictions. Ms. Goad returned to the clinic
several times over the next month before she was referred to an orthopedic specialist.
Ms. Goad’s first two selections from the orthopedic panel refused to see her,
so instead of requesting a new panel, she selected Dr. Burleson to avoid further
delay.
1
At her first visit in January 2024, she told him about suffering immediate sharp
pain in her back when “she was hit by a towmotor” at work. Ms. Goad also reported
developing some radicular symptoms in her leg. An MRI showed L4/5 grade 1
spondylolisthesis, and Dr. Burleson felt it likely that “was made worse with her
accident.” He continued her restrictions and suggested epidural steroid injections.
When those were unsuccessful, Dr. Burleson recommended anterior lumbar
interbody fusion surgery, as she had “a disc bulge that is placing pressure on her
nerves causing . . . significant radiculopathy.”
Capstone then sent Dr. Burleson two medical questionnaires. The first asked
whether Ms. Goad’s spine problems were more than 50% related to her work
accident. Dr. Burleson selected “no” and explained that some of her symptoms, such
as her back pain, were mainly related to her accident. But he attributed her need for
fusion as greater than 75% related to her “chronic, degenerative condition.” He also
answered “no” to whether a lumbar fusion was more than 50% related to the work
injury.
Dr. Burleson’s later notes show that surgery was not approved. He continued,
however, to recommend the operation over the next few months. In January 2025,
Dr. Burleson explained, “I do believe she had a work injury which made her chronic
back condition symptomatic.” Following a functional capacity evaluation, he
determined she reached maximum medical improvement on March 11 and assigned
a permanent impairment rating.
Capstone sent another medical questionnaire to Dr. Burleson in June. Asked
whether he still believed Ms. Goad’s need for lumbar fusion was not more than 50%
related to her work accident, he responded, “yes.” He also indicated that none of
her future treatment was more than 50% related to the work injury.
Ms. Goad began seeing Dr. Melvin Law, an unauthorized orthopedic surgeon.
The only treatment record from Dr. Law entered into evidence is an office note of
July 23, 2025. He diagnosed spondylolisthesis at L4-5 with significant moderate to
severe lateral recess stenosis and recommended anterior lumbar interbody fusion.
In response to a letter from Ms. Goad’s attorney, Dr. Law wrote that because
Ms. Goad denied having any back problems or pain before her work accident, she
likely suffered an annular tear. This made her spondylolisthesis unstable and caused
her to become symptomatic. Dr. Law also executed a Form C-32 Standard Form
Medical Report in which he described the mechanism of injury as a “fall after being
2
hit by a tow motor at work.” He believed her work accident was primarily
responsible for both advancing her pre-existing condition and the present need for
treatment of that condition.
Dr. Burleson testified via deposition that a video of the accident did not
change his opinion. His initial impression of Ms. Goad’s injury was based on her
description of being hit by a towmotor. After reviewing the video, the incident was
less violent than he originally thought. However, it did not materially change his
opinion, and he reiterated that Ms. Goad’s need for fusion surgery was not more than
50% related to her work injury. He explained, “[A]fter seeing the mechanism [of
injury] again, I don’t think there was enough in that injury to worsen her spine to
cause the symptoms that she’s having.” Dr. Burleson also thought Dr. Law’s
suggestion of an annular tear was speculation and that the MRI did not indicate one.
On cross-examination, Dr. Burleson agreed that Ms. Goad reported her
symptoms had begun immediately after the accident. He also said that her nerve
roots were not causing symptoms before the accident and that Ms. Goad would not
need surgery at this time if she were asymptomatic.
Dr. Burleson was asked about his January 14, 2025 note, where he wrote:
I believe the majority of her need for surgery is due to her chronic low
back condition and not her work injury. I do think the work injury is
greater than 50% responsible for the symptoms she experienced after
the injury and therefore the immediate treatment. However, I do not
believe that the need for surgery is mainly from this work injury.
This led to the following exchange:
Q. Again, asymptomatic before the accident, right?
A. Yes, sir.
Q. Immediately became symptomatic, correct?
A. Correct.
Q. Symptomatic because of the aggravation of a pre-existing
condition?
A. I think that’s fair to say.
Q. And it was only the accident that aggravated the pre-
existing condition, right?
A. I believe that’s correct.
3
Finally, Dr. Burleson was shown a notation in the clinic records that read,
“Has injured her back years ago but no prior back surgery.” He said that did not
affect his causation opinions.
Based on Ms. Goad’s Rule 72 Declaration and her testimony, she injured her
back while working for another employer sometime before 2005 that caused pain in
her shoulders. She sought treatment through her health insurance but received no
surgery, injections, or physical therapy. Instead, she worked a period of light duty
before returning to her regular duties, after which the symptoms disappeared, and
she had no problems for 20 years.
Ms. Goad worked for two to three years at Capstone, packing cookies and
biscuits on a production line. She could do her job with no limitations, no injuries,
and no lumbar spine symptoms until the accident in September 2023.
Ms. Goad’s description of the accident was inconsistent. She previously
described being hit by the towmotor or being hit by the pallet the towmotor was
carrying. However, she testified during the hearing that she was standing and
working at a table when a pallet on the floor behind her struck her in the back of the
legs, which caused her to fall backward. She was unable to catch herself, and she
landed on the pallet in a seated position. As soon as she fell, Ms. Goad felt severe
low back pain. Her leg pain, which she had never had before, began a few weeks
later.
While receiving medical treatment, Ms. Goad continued working light duty
until October 1, 2024, when Capstone could no longer accommodate her restrictions.
She then began receiving full temporary disability benefits that continued until Dr.
Burleson determined she had achieved maximum medical improvement. She has
not been able to work anywhere since, and her condition has worsened since she last
saw Dr. Burleson.
Ms. Goad requested an order for continuing medical treatment, specifically
the surgery ordered by Dr. Burleson. She also asked that Dr. Law perform the
operation and be designated as her authorized physician. Ms. Goad also contended
that she is entitled to additional temporary total disability benefits from March 11,
2025, the date they were terminated, to the present.1
1 She also requested payment of additional temporary partial disability benefits for the period she
was working light duty. However, following the hearing, the parties notified the Court that they
had reached an agreement on this issue.
4
Capstone countered that it furnished or paid all benefits to which Ms. Goad
was entitled. Relying on Dr. Burleson, whose opinion is presumed correct, it argued
that any aggravation to her underlying spine condition was not primarily caused by
her work accident. Therefore, Capstone is not responsible for the recommended
surgery. Further, Ms. Goad is not entitled to additional temporary disability benefits
because Dr. Burleson said she had reached maximum medical recovery, and that
opinion was never retracted.
Findings of Fact and Conclusions of Law
Ms. Goad must show she is likely to prevail at a hearing on the merits. Tenn.
Code Ann. § 50-6-239(c)(6) (2025); McCord v. Advantage Human Resourcing, 2015
TN Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9 (Mar. 27, 2015).
Causation
Regarding the surgical recommendation, the parties disagreed whether Ms.
Goad’s work accident was the primary cause of the aggravation of her pre-existing
diagnosed spondylolisthesis. They agreed, however that the controlling law is in
Edwards v. Peoplease, LLC, No. W2024-01034-SC-R3-WC, 2025 Tenn. Lexis 514
(Tenn. Dec. 22, 2025) (2013 Reform Act established a new standard for determining
whether an aggravation is compensable).
Addressing the standard for proving an aggravation, the Supreme Court first
summarized the statutory requirements for establishing compensability:
For aggravation injuries, the claimant must show, to a reasonable
degree of medical certainty, that the aggravation primarily arose out of
and in the course and scope of employment. This requires the employee
to demonstrate that the employment contributed more than fifty percent
in causing the aggravation. Finally, the employee must establish that
the aggravation of the pre-existing condition contributed more than
fifty percent in causing the death, disablement, or need for medical
treatment, to a reasonable degree of medical certainty. Further, the
“opinion of the treating physician, selected by the employee from the
employer’s designated panel of physicians . . . shall be presumed
correct on the issue of causation," but the employee can overcome this
presumption "by a preponderance of the evidence.”
5
Edwards, 2025 Tenn. Lexis 514 at*23-24.
The court then explained that “aggravation” means “intensification or
worsening of a preexisting disease, condition or ailment, permanent or not, that
contributes more than fifty percent in causing death, disability or the need for
medical treatment.” Id. at*26. (emphasis added). Ms. Goad therefore must prove
she is likely to show (1) that the work accident contributed more than fifty percent
in causing the aggravation, and (2) that the aggravation, which was caused by the
work accident, contributed more than fifty percent to disablement or the need for
medical treatment.
Capstone argued that Ms. Goad’s previous back problems foreclose her claim
for aggravation. It contended that the Edwards court focused on Ms. Edwards’s lack
of symptoms before her accident. Ms. Goad, on the other hand, admitted to having
back pain in the past. Capstone maintained that her claim is distinguishable because
Edwards “makes no distinction about timing of symptomology prior to the work
injury or how resolution of prior symptomology before recurrence . . . affects the
analysis.”
Capstone may be correct that the facts in Edwards are different, in that Ms.
Goad may have had back pain in the past. However, just because the court did not
set out specific parameters does not mean that its holding is limited to workers with
pristine medical histories. To the contrary, the plain language of the opinion says
any intensification causing more than 50% of the need for treatment is a
compensable aggravation. This suggests that a worsening of previous symptoms is
to be included in the analysis.
Further, the evidence in this case does not establish that Ms. Goad’s previous
symptoms were related to or even like her current problem. The parties offered no
medical records from the earlier treatment, and the only specifics were Ms. Goad’s
testimony that her shoulders hurt, which is a very different complaint from her
current symptoms.
Capstone also contended that the accident video validates Dr. Burleson’s
opinion. It argued that the events in the video do not square with Ms. Goad’s
accident description. Further, the mechanism of injury was inconsistent with what
she described to her providers.
The Court agrees that Ms. Goad’s description of the accident was inconsistent
with the video. Even watching the recording while she was on the stand, her
6
narration of the events was nearly incomprehensible. In short, Ms. Goad is a very
poor historian, but she was generally credible. Further, the Court viewed the
recording, and the video supports the main points. That is, a pallet hit the back of
her legs, and she fell backwards into a seated position on it.
The problem with Capstone’s reliance on Dr. Burleson’s conclusion that the
mechanism of injury was insufficient to cause Ms. Goad’s problems is that Dr.
Burleson’s deposition testimony was also inconsistent. He reviewed the video after
already concluding that her need for fusion surgery was not more than 50% related
to her work injury. He then said it did not change his opinion and added, “I don’t
think there’s enough in that injury to worsen her spine to cause the symptoms that
she’s having.2”
However, Dr. Burleson also acknowledged that Ms. Goad only became
symptomatic after the accident because of the aggravation of a pre-existing
condition. He then agreed the accident was the only cause of the aggravation, which
precisely meets the requirements of Edwards. He did not explain how the accident
could be the sole cause of the aggravation yet insufficient to cause her symptoms.
Dr. Burleson’s causation opinion is presumed correct under section 50-6-
102(12)(E). But how is the Court to apply the statutory presumption when his
testimony was inconsistent on this question? The conflicting opinions make it
difficult to credit his reservations regarding the mechanism of injury, so one
approach would be to discount his testimony entirely. Clay v. Signature Healthcare,
2019 TN Wrk. Comp. App. Bd. LEXIS 58, at *22 (Oct. 21, 2019) (relying on the
doctor’s various causation opinions was problematic, as it was impossible to discern
what his opinion actually was). This would leave only Dr. Law’s opinion that Ms.
Goad’s work injury was primarily responsible for both advancing her pre-existing
condition and for her present need for treatment.
On the other hand, the Court might conclude that, given the diametrical nature
of his responses on this issue, Dr. Burleson simply did not understand how to apply
the legal standard of causation to his understanding of Ms. Goad’s symptoms. In
that situation, the Court might credit only the factual parts of Dr. Burleson’s
testimony and not his opinion on the ultimate issue, which would support Dr. Law’s
opinion. Or the Court might simply assign less weight to Dr. Burleson’s opinion
because of its inconsistency. This would weaken his testimony to the point that the
2 Dr. Burleson said several times that the accident was part of the cause of her need for treatment,
just not 50%.
7
presumption of correctness is easily overcome by Dr. Law’s contrary opinion.
Further, Dr. Burleson’s conclusion about Ms. Goad’s symptoms being caused
by the work accident is supported by her own testimony. Caskey v. Powers Pizza,
LLC, 2015 TN Wrk. Comp. App. Bd. LEXIS 37, at *9 (Oct. 7, 2015) (live testimony
by a lay witness may influence the trier of fact in considering expert medical proof).
As noted above, she was not a good historian, but she was a very credible witness
regarding her physical condition and limitations. She did not appear to exaggerate
her complaints of pain; her demeanor was consistent with one who had endured pain
for some time; and her need for relief was believable. Against this backdrop, she
testified that she was completely asymptomatic before the accident, when she
immediately developed serious pain. Capstone offered no proof to rebut this
testimony.
For these reasons, applying the Edwards standard to the facts of this case, the
Court finds that Ms. Goad is likely to prove entitlement to the surgery offered by Dr.
Burleson.
Medical Treatment
Ms. Goad asked that Dr. Law perform the operation and be designated as her
authorized physician. If an employer refuses to provide medical treatment or denies
an employee’s claim, it runs the risk that an employee's chosen physician will be
designated the authorized physician. Blevins v. S. Champion Tray, LP, 2019 TN
Wrk. Comp. App. Bd. LEXIS 29, at *16-17 (July 11, 2019).
In this case, Capstone did not deny Ms. Goad’s claim but furnished medical
panels and treatment. It later denied the fusion surgery, but it did so because the
authorized doctor said her injury and need for treatment were not more than 50%
caused by her work accident. Under the circumstances, the Court finds she is
unlikely to prove she is entitled to a change of physicians.
Temporary Disability
Ms. Goad requested payment of additional temporary total disability benefits
from March 11, 2025, the date they were terminated, to the present.
The request for temporary total disability benefits is a misnomer, as an injured
worker is eligible for those benefits only when she is completely unable to work.
Jones v. Crencor Leasing and Sales, 2015 TN Wrk. Comp. App. Bd. LEXIS 48, at
8
*7-8 (Dec. 11, 2015). Ms. Goad was not taken off work completely during the
relevant time period but may have been on light-duty restrictions for all or part of it.
Thus, the appropriate question is whether she is entitled to temporary partial
disability benefits. For this, she must show that her treating physician assigned
temporary restrictions that Capstone either could not or would not accommodate.
Id.
The hurdle for Ms. Goad is that temporary partial disability benefits end once
the employee is able to return to work or has reached maximum medical
improvement. Hackney v. Integrity Staffing Solutions, Inc., 2016 TN Wrk. Comp.
App. Bd. LEXIS 29, at *11 (July 22, 2016).
According to Dr. Burleson, Ms. Goad reached maximum medical recovery on
March 11, 2025. Normally, this would mean she could not receive temporary
disability benefits after that date. Williams v. Saturn Corp., No. M2004-01215-WC-
R3-CV, 2005 Tenn. LEXIS 1032, at *8 (Tenn. Workers’ Comp. Panel Nov. 15,
2005). But the rule has an exception. If a maximum medical improvement
determination is “premature and incorrect,” temporary disability benefits may still
be awarded. Mansell v. Southeast Personnel Leasing, Inc., 2025 TN Wrk. Comp.
App. Bd. LEXIS 9, at *11 (Mar. 12, 2025). However, an employee “still must show
that he would likely prevail at trial in proving that the original [maximum medical
improvement] determination was premature.” Id.3
The Supreme Court Workers’ Compensation Panel held that the initial
maximum improvement determination was premature and incorrect when an MRI,
approximately one year later, revealed the need for additional surgery. Wise v.
Murfreesboro Health Care Ctr., no number in original, 1994 Tenn. LEXIS 389, at
*9 (Tenn. Workers’ Comp. Panel Dec. 22, 1994). Similarly, the Board recently held
that additional temporary benefits were proper when an employee experienced
additional symptoms after reaching maximum improvement, an MRI revealed
severe post-traumatic arthritis, and the doctor retracted his opinion. Laymance v. K-
VA-T Food Stores, Inc., 2026 TN Wrk. Comp. App. Bd. LEXIS 2, at *12 (Jan. 14,
2026).
3 The Court was unable to identify any specific authority on this question as to temporary partial
disability benefits. Mansell and the other cases cited addressed temporary total disability rather
than partial. However, both partial and total disability benefits share the limitation of maximum
medical improvement terminating the right to benefits. Thus, the analysis is the same , and the
Court views these cases as controlling authority.
9
Wise and Laymance are distinguishable from this case. Unlike the employees
in those cases, Ms. Goad offered no evidence that her symptoms or her underlying
medical condition changed significantly after Dr. Burleson said she reached
maximum medical improvement.
Instead, like the employee in Mansell, Ms. Goad offered no expert proof that
Dr. Burleson “placed [her] at [maximum medical improvement] prematurely or that
he has retracted that determination or otherwise reversed his opinion.” Mansell,
2025 TN Wrk. Comp. App. Bd. LEXIS 9 at *11. In fact, Dr. Burleson testified, “I’m
saying that, where she is now with surgeries that she [w]as offered her currently . . .
that she has reached maximum medical improvement with our treatments.” Like the
Mansell court, this Court cannot find that the doctor’s original determination was
premature or medically incorrect without any expert medical opinion to support that
conclusion. That kind of speculation is improper, as courts cannot formulate their
own medical opinions. Id. For this reason, Ms. Goad has not yet shown she is likely
to prove entitlement to temporary partial disability benefits from March 11, 2025, to
the present.
IT IS, THEREFORE, ORDERED as follows:
1. Capstone shall provide Ms. Goad with medical treatment made reasonably
necessary by her September 23, 2023 injury under Tennessee Code Annotated
section 50-6-204, including the surgery recommended by Dr. Burleson, who
shall remain her authorized doctor.
2. Ms. Goad’s request for temporary partial disability benefits is denied at this
time.
3. A status hearing will take place on July 1, 2026, at 10:00 a.m. Central Time.
The parties must call 615-741-2112 to participate.
4. Unless an interlocutory appeal of the Expedited Hearing Order is filed,
compliance with this Order must occur no later than seven business days from
the date of entry of this Order as required by Tennessee Code Annotated
section 50-6-239(d)(3).
ENTERED April 21, 2026.
10
____________________________________
JUDGE DALE TIPPS
Court of Workers’ Compensation Claims
APPENDIX
Exhibits:
1. Rule 72 Declaration of Kathy Goad
2. Dr. Law’s C-32 Standard Form Medical Report
3. Indexed medical records
4. Employee’s additional medical records
5. Video recording of accident
6. Printouts of Ms. Goad’s earning statements
7. Summary of Ms. Goad’s weekly earnings and temporary partial disability
payments
8. Ms. Goad’s answers to first set of interrogatories and requests for production
9. Capstone’s responses to first requests for production
10. Emails between counsel regarding Ms. Goad’s panel selections
11
CERTIFICATE OF SERVICE
I certify that a copy of this order was sent as shown on April 21, 2026.
Name Mail Email Service sent to:
R. Steven Waldron, X arlenesmith@wfptnlaw.com
Employee’s Attorney
Ryan Mirian, X rmirian@eraclides.com
Employer’s Attorney
____________________________________
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.
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.
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 (check one or more applicable boxes and include the date file-
stamped on the first page of the order(s) being appealed):
□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________
□ Compensation Order filed on__________________ □ 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 *
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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