The image is a scanned document with visible text at the top that reads "COURT OF APPEALS DIVISION ONE" followed by an address and phone number. The document appears to be related to legal proceedings, specifically an appellate court, as indicated by the header. It contains form fields with instructions for completing the document, though specific details like names or case numbers are not legible due to the quality of the scan. There's a red stamp or mark at the top right corner, but it's unclear what it says. The overall style is formal and legalistic, typical of official court documents.