public in and for said county personally appeared... known to me to be the persons described in and who signed the foregoing stipulation, and acknowledged that they signed the same as their free act and deed. And I further certify that I read over all of said stipulation to said persons, and fully acquainted them with the contents thereof before the same was acknowledged and signed by him (them).

known to me to be the person who signed the foregoing stipulation on behalf of. . . . .

the employer therein mentioned, and acknowledged that he executed the same on behalf of said...

being duly authorized so to do, and that the same is his free act and deed as. . for said employer.

(State position or office.)

My commission expires on the. . . . . . . . day of...

FORM NO. 19

Notary Public.

Application for review of claim before full board

(Part 3, §§ 11 and 12)

To the Industrial Accident Board, Lansing, Mich.

Gentlemen: The undersigned, as provided in Part 3, Sec. 8, of Act No. 10, Public Acts 1912, makes application for a review of the

Minnesota

findings of the Committee on Arbitration in the claim of...................

This claim for review is based on the following grounds:

VS.

Dated at.....

this.

day of.

19...

MINNESOTA

The parties may settle all questions relating to compensation between themselves. Part II, § 22. But the settlement must be approved by a judge of the District Court. Part II, § 22. Upon failure of the employer to pay the compensation for thirty days in accordance with the approved agreement the employé may apply, upon a notice of five days, for judgment, and such judgment shall have the same force and effect and may be specified as other judgments of the same court. Part II, § 22. In case of dispute the matter may be submitted to a judge of the District Court who is authorized to hear the case in a summary manner and his decision on all questions of fact is conclusive, subject to the right of appeal on questions of law. Part II, § 22 (2). The Labor Commissioner of the State has general supervision of the Act and is required to advise employés of their rights thereunder. Part II, §§ 24 and 28. The specific procedure in case of dispute is provided for in Part II, § 30.

The undersigned, being the only parties interested in the aboveentitled matter, hereby petition the Court for approval of the following agreement and settlement, and agree and represent to the Court as follows:

. years, residing at....

That they are subject to the provisions of Part II of Chapter 467 of the Laws of Minnesota of 1913; that the said Employé, aged.... Minnesota, who can (cannot) read and understand the English language, did, on 191., at.........o'clock.... ..o'clock..... .. .M., sustain injury by accident while employed by said Employer, which injury occurred at..... .....and resulted in...

(Permanent Total, Permanent Partial, or Temporary.)

disability of said Employé, and consisted of..

that said Employé was receiving at the time of the injury wages at the rate of $........ per week;

Therefore, it is hereby agreed that the Employé is entitled to and shall receive compensation for said injury from the Employer, beginning... 191., at the rate of $.....

per week during disability (or) for.. as follows:.

weeks, payable

.all subject to the

limitations of said Act; and the Employé agrees to give proper receipts for each payment made hereunder.

The Employé hereby acknowledges that he has received to date medical and surgical treatment and benefits given by Section 18, Part II, of said Act, and the Employer agrees to continue to furnish the same, if any be necessary, to the extent and in the manner required by said Section. The Employé agrees to present himself

Minnesota

for examination, or if physically unable to do so, to submit himself to examination by the physician or physicians designated by the Employer, when requested.

This settlement is substantially in accordance with Sections 13 and 14 of said Act. When all payments hereunder have been made the Employer shall be, and hereby is, released from all claims on account of said injury, under said Act or otherwise. This settlement contains the whole agreement between the parties hereto. Dated at.... ..191.. Witnessed by

.to me known to be the iden

before me, a Notary Public within and for said County and State, personally appeared. tical person described in the foregoing instrument as Employé, and acknowledged that the same is true; and that, after reading the same (or) having the same read to. and with a full un

derstanding of the terms and the effect thereof,..

do hereby on my oath say, that I understand, read and speak

Minnesota

readily the English language; that I correctly read over to... ..said injured Employé, and correctly interpreted to ... . . . in....... ...own language, the true and correct meaning of each word in the foregoing instrument and the acknowledgment thereof; and that.......... executed said instrument and acknowledged the execution of the same after I had interpreted and fully explained the same to........; and I further say that I am conversant with the language spoken by said injured Employé, which is that of....

upon oath say, that I am a physician, duly licensed to practice in the State of Minnesota; that I professionally attended... the person described as Employé in the foregoing instrument; that injury and the nature and extent of........disability are as follows: