APPEAL TO THE ADMINISTRATIVE COURT
(basic social assistance)

Recipient: [THE ADMINISTRATIVE COURT OF YOUR REGION — the name and address
are stated in the appeal instructions of the review decision]

Appellant:
[FIRST NAME LAST NAME]
[PERSONAL IDENTITY CODE]
[ADDRESS]
[PHONE NUMBER]

Decision appealed:
Decision of Kela review centre concerning basic social assistance
Review decision number: [NUMBER]
Date of the review decision: [DATE]
Original decision: [NUMBER, DATE]

My claim:
I request that the review centre decision be [revoked / amended] so that
[WHAT YOU CONCRETELY DEMAND].

Grounds:
[STATE THE SAME GROUNDS AS IN THE REQUEST FOR REVIEW AND IN ADDITION:

The review centre decision stated that [BRIEFLY SUMMARISE THE GROUND FOR
THE REJECTION]. This is incorrect, because [EXPLAIN WHY — new evidence,
incorrect interpretation or changed situation].]

Attachments:
1. Review centre decision [DATE]
2. The original social assistance decision [DATE]
[3. OTHER ATTACHMENTS — e.g. new medical statement, bank statement,
invoices]

[DATE]
[SIGNATURE AND NAME IN PRINT]