UCS- 872- Effective January 1, 2004 NOA # Notice of Appointment and Certification of Compliance (Pursuant to 22 NYCRR § 36.4) DATE OF APPOINTMENT: / / Month Day Year Non-List Notice of Appointment PART A 1. Appointee's Name and Fiduciary Identification Number: FID# Name: First Suffix (Jr., Sr., III) Last Middle 2. Address/Phone/FAX/Email: Business Name (if any) Street City/Town/Village Phone State Zip E-Mail Fax 3. Type of Appointment: 4. Index/File No.: Number 5. Court: 6. County: / Year 8. Case Type: 7. Title of Action/Proceeding: 9. Appointing Judge: First Last Middle Suffix (Jr., Sr., III) Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com UCS- 872- Effective January 1, 2004 INSTRUCTIONS TO APPOINTEE . Review the information in items I and 2 of Part A (Notice of Appointment) for accuracy; circle errors and enter corrections on form. . If Fiduciary Identification Number does not appear in Part A, an appointed individual must enter Social Security Number; an appointed entity must enter Tax Identification Number: - SS/TID# - (Social Security/Tax Identification Number is required in administer the disbursement of moneys that may constitute taxable income. 42 U.S.C. § will not be made public.) 405(c)(2)(C)(1). Social Security/Tax Identification Number . Appointment WITH compensation: Complete Part B (Certification of Compliance); date and sign item 3 of Part B. • Appointment WITHOUT compensation: do NOT complete Part B (Certification of Compliance); date and sign here: Signature Date . Return completed form as soon as possible, but no later than 30 days after appointment, to the Fiduciary Clerk for the court of appointment IF UNABLE TO ACCEPT APPOINTMENT FOR ANY REASON, NOTIFY FIDUCIARY CLERK IMMEDIATELY. PART B Certification of Compliance 1. Appointment in Part A- If the compensation anticipated to be awarded in any single calendar year (current or future) is $15,000 or more, mark ''X'' in the box in Column E. A Index/File No. (Number/year) B Court C County D Appointing Judge F Anticipated Compensation of $15,000 or more / Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com UCS- 872- Effective January 1, 2004 2. Part 36 appointments RECEIVED during CURRENT calendar year a) Review information for current calendar year appointments provided below from the records of the Office of Court Administration; circle errors and enter corrections on this form. b) In the blank spaces below, provide information for all current calendar year appointments not pre-recorded on this form. c) Mark ''X'' in the box in Column E for any appointment (including prerecorded appointments) for which compensation of $15,000 or more is anticipated to be awarded in any single calendar year (current or future). Include compensation already awarded in calculating anticipated compensation for the current calendar year. A B C D E Index/File No. Court county Appointing Judge Anticipated Compensation 0f $15,000 or more (Number/year) / Judge / Judge / Judge / Judge / Judge / Judge / Judge / Judge / / Judge Judge Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com UCS- 872- Effective January 1, 2004 3. Part 36 appointments for which compensation was AWARDED during PRIOR calendar year a) Review information for prior calendar year compensation provided below from the records of the Office of Court Administration; circle errors and enter corrections on this form, b) In the blank spaces below, provide information for all appointments not prerecorded on this form for which compensation was awarded during the prior calendar year. c) Total all amounts of compensation entered in Column E (including pre-recorded amounts) in the space provided at the bottom of the column. A B Index/File No. (Number/year) Court D Appointing Judge C County E Compensation Awarded / Judge $ / Judge $ / Judge $ Judge $ / Judge $ / Judge S / Judge $ / Judge $ / Judge $ / Total compensation awarded during prior calendar year 4. from Column E: $ I certify that I am in compliance with sections 36. (c) and (d) of the Rules of the Chief Judge (22 NYCRR) for the appointment in Part A of this form. Date: Signature: Fiduciary Clerk should submit all completed statements to: Appointment Processing Unit, 25 Beaver Street, Room 840, New York, NY 10004 Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com