Supreme Court of the State of New York Appellate Division: Second Judicial Department In the Matter of ATTORNEY'S CERTIFICATE OF APPELLANT'S CONTINUED ELIGIBILITY FOR POOR PERSON RELIEF AND ASSIGNMENT OF COUNSEL ON APPEAL Appellate Division Docket No.: against ________________________ THIS FORM MAY NOT BE USED IN ANY CASE IN WHICH THE FAMILY COURT, AFTER THE ASSIGNMENT OF COUNSEL, HAS ISSUED AN ORDER FINDING THAT THE APPELLANT IS OF SUFFICIENT MEANS TO PAY SPOUSAL OR CHILD SUPPORT, OR ARREARAGES THEREOF. I, ___________________________________, an attorney admitted to practice in the State of New York, hereby certify, pursuant to Family Court Act § 1118 and CPLR 1101, that: 1. I am an attorney duly licensed to practice in the State of New York, and a member of an assigned counsel program OR employed by _______________________, which is a legal aid or legal services program representing indigent parties (strike one). 2. I was assigned as counsel for _______________________, the petitioner/respondent in the above-entitled proceeding, upon a determination of the Family Court, ______________ County, pursuant to Family Court Act § 262, that the he/she was indigent and unable to afford the costs, fees, and expenses of the proceeding, and was entitled to the assignment of counsel. 3. On behalf of _______________________, I filed a notice of appeal from an order of the Family Court, ______________ County, dated ______________ ___, 200_, which ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________ (set forth the nature of the order). Copies of the order appealed from, the notice of appeal, and any separate decision are attached hereto. 4. To the best of my knowledge, (1) since the date of my assignment, the appellant has not been found to be of sufficient means to pay spousal or child support or any arrearages thereof, and (2) the financial status of the appellant has not changed from the date the Family Court, ______________ County, determined that he/she was entitled to the assignment of counsel, and (3) he/she is presently, and for the foreseeable future will be unable to afford the costs, fees, and expenses of the above-entitled appeal. American LegalNet, Inc. www.USCourtForms.com 5. To the best of my knowledge, _______________________ is interested in prosecuting the appeal. The appellant's last known address is as follows: 6. I wish to be assigned to represent ________________________ on the appeal in the aboveentitled proceeding. OR 6. I cannot represent _______________________ on the appeal in the above-entitled proceeding, and request that another attorney be assigned to represent him/her. 7. A copy of this certification is being provided to the County Attorney, and to counsel for each other party, or to the party if appearing pro se, and to the law guardian, if any. Dated: ___________________, New York ________________ ___, 200___ ____________________________________ The following persons have been provided with a copy of the foregoing certificate: American LegalNet, Inc. www.USCourtForms.com