State of __________, county of __________, town of __________, ss.: 

Whereas, a road was laid out (or altered or discontinued) on the day of
__________, A.D. 18_____, by the undersigned supervisors of the said town
of __________, on the petition of (six) legal voters, owning real estate,
or occupying real estate under the homestead or pre-emption laws of the
United States, or under contract from the state of __________, within one
mile (or eight legal voters, freeholders and residents of the town within
two miles) of said road; which said road (or alteration, or
discontinuance) is set forth and described in the supervisors’ order as
follows, viz.:  Beginning (describe the road as in the order laying it
out.) And not being able to agree with the owners of the following
described lands, claiming damages by reason of said highway passing
through, we have assessed the damages to each of such individual claimants
with whom we could not agree, and awarded damages to the owners of such
lands through which such highway passes as are unknown, at what we deemed
just and right; taking into account and estimating the advantages and
benefits the road will confer on the claimants and owners, as well as the
disadvantages.  We have assessed and awarded damages as follows: 

(Here give a particular description of each tract of land and its owner, if known; but if not known, state that fact also.)

And in case of the following lands and claimants for damages, we estimate that the advantages and benefits said road will confer on them are equal to all damages sustained by them by reason of laying out (or altering, or discontinuing) said road, to-wit:  (Set forth lands and owners as far as known; and describe the unknown lands, stating that the owners are unknown.) (Dated, and signed by the supervisors.)

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.)