Wash. R. App. P. Form 21 (2026)

See RAP 18.17 for document formatting requirements.

RAP FORM 21. Civil Appeal Statement

(Rule 5.5(c))

COURT OF APPEALS, DIVISION_____ OF THE STATE OF WASHINGTON

(Title of trial court proceeding ) with parties designated as in ) CIVIL rule 3.4 ) APPEAL STATEMENT

1. NATURE OF THE CASE AND DECISION

(State the substance of the case below and the basis for

the trial court decision. For example: "Defendant was driving

his automobile when struck from the rear by a truck driven by

Jones. An automobile coming from the opposite direction

driven by an uninsured motorist crossed the center line into the

lane occupied by defendant and collided with the defendant's

car. Defendant settled his claim against Jones and executed a

release without the consent of plaintiff insurance company. The

policy issued by plaintiff contained a provision which excluded

coverage under the uninsured motorist provisions for bodily

injury to an insured who has made any settlement with any

person without the written consent of the company. The trial

court held that this exclusion violated public policy by

restricting the uninsured motorist coverage required by RCW

48.22.030 and declared the exclusion void.")

2. ISSUES PRESENTED FOR REVIEW

(State the issues the party intends to present for review

by the Court of Appeals. For example: "Whether a provision

which excludes coverage when the insured does not secure the

insurer's consent before settling with any person responsible for

any injury violates public policy by restricting the uninsured

motorist coverage required by RCW 48.22.030?" List under

each issue the legal authority relevant to that issue.)

3. RELIEF SOUGHT IN COURT OF APPEALS

(State the relief the party seeks in the Court of Appeals.

For example: "Reversal of trial court decision with directions

to enter judgment declaring that defendant is not covered by the

uninsured motorist provisions of the liability policy issued by

plaintiff.")

4. TRIAL COURT

(Name of County) County Superior Court

5. JUDGE

(Name of Trial Court Judge)

6. DATE OF DECISION

(The date the decision was entered in the trial court)

7. POST-DECISION MOTIONS

(State each post-decision motion made in the trial court

including the nature of the motion, the date the motion was

made, the decision on the motion, and the date the decision was

entered.)

8. NOTICE OF APPEAL

The notice of appeal was filed on date. A copy of the

notice of appeal is attached to this statement.

9. COUNSEL

Counsel for appellant (name of appellant) is (name,

address, and telephone number of attorney). Counsel for

respondent (name of respondent) is (name, address, and

telephone number of attorney).

10. METHOD OF DISPOSITION IN TRIAL COURT

(State the method used to decide the case in the trial

court. For example: "summary judgment, order of dismissal,

judgment after trial to the court, judgment after jury trial.")

11. RELIEF GRANTED BY TRIAL COURT

(State the relief granted by the trial court. For example:

"The trial court entered a judgment declaring that defendant has

coverage under the uninsured motorist provisions of the

automobile liability policy issued by plaintiff.")

12. RELIEF DENIED BY TRIAL COURT

(State the relief sought by the party making the statement

which was denied by the trial court. For example: "Plaintiff

sought a judgment declaring that the uninsured motorist

provision of the automobile liability policy no longer provided

coverage to defendant.")

13. CERTIFICATE OF COUNSEL

I, attorney for appellant (name of appellant), certify that

this appeal is taken in good faith and not for purposes of delay.

I further certify that my client (is or is not) prepared to

immediately take all steps to complete the appeal. (If the

statement indicates the party is not prepared to immediately

take all steps to complete the appeal, state here why the party is

not prepared to immediately complete the appeal.)

_____________________ (Date)

_____________________________________ Signature Attorney for Appellant (Name, personal pronouns (optional), address, telephone number, and Washington State Bar Association membership number of attorney)

[Adopted effective July 1, 1976; Amended effective September 1, 1994; June 27, 2023.]