APPLICATION FOR JURY.
State of __________, county of __________, town of __________, ss.
To J.P., justice of the peace in and for said county:
I, J.A.B., of said town, feeling myself aggrieved by the determination (award of damages) made by the supervisors of said town (county commissioners of said county) by their order bearing date the _____ day of __________, A.D. 18_____, in laying out (altering or discontinuing) (or refusing to lay out, alter or discontinue) a highway in said town (county), do hereby appeal to you for a jury to be summoned by you to hear and determine such appeal.
The highway (alteration or discontinuance) in question is described in said order, filed in the town clerk's (county auditor's) office of said town (county) ________, A.D. 18_____, as follows: (describe the road, as in the order on file), which said road passes through lands owned by me, viz.: (describing them.)
The grounds upon which this appeal is brought, are: (to recover $80 damages to my said land by reason of such laying out, instead of $40 as awarded in said order) (or, in relation to the laying out, or altering, or discontinuing said highway;) (or their refusal to lay out, or alter, or discontinue said highway;) (or said appeal is brought to reverse entirely the decision of the said supervisors or commissioners;) (or is brought to reverse that part of their order [specifying which part,] &c.) (Dated and signed by the appellant.)