Signed (Counsel of record) u 1. Preliminary Statement of the Issues 2. Court Reporter's Acknowledgment or Certificate that no transcript is necessary 3. Docketing Statement Appeal Type of appellate matter (If a writ of error, the writ and the signed marshal's return must be filed on the same business day as this form. See Practice Book Section 72-3.) JD-SC-33 Rev. 11-17 P.B. Sections 3-8, 60-7, 60-8, 62-7, 62-8, 63-3, 63-4, 63-10, 72-3 C.G.S. Sections 31-301b, 51-197f, 52-470 To Supreme Court Trial Court History Tried to Trial court location Trial court judges being appealed All other trial court judges who were involved with the case List all trial court docket numbers, including location prefixes Judgment for (Where there are multiple parties, specify those for whom judgment was rendered) Date of judgment(s) or decision(s) being appealed Date for filing appeal extended to Case type For Civil/Family Case Types, Major/Minor code: Appeal filed by (Party name(s))For Juvenile Cases Termination of Parental Rights Order of Temporary Custody Other From (the action that constitutes the appealable judgment or decision) By (Signature of counsel of record) u Statutory Basis for Appeal to Supreme Court Telephone number Fax number Juris number (If applicable) Appearance "X" one if applicableCounsel or self-represented party who files this appeal will be deemed to have appeared in addition to counsel of record who appeared in the trial court.Counsel or self-represented party who files this appeal is appearing in place of: Type name and address of counsel of record filing this appellate matter (This is your appearance; see Practice Book Section 62-8) Name of counsel of record Juris number (If applicable) Name of case (State full name of case) Certification Court Use Only Date and time filed APPEAL JOINT APPEAL CROSS APPEAL CORRECTED FORMAll appeals must be filed electronically unless an exemption from the requirements of electronic filing has been granted or you are an incarcerated self-represented party. For further information about e-filing or this form, see the Appeal Instructions, form JD-SC-34. If this appeal is taken by the State of Connecticut, provide the name of the judge who granted permission to appeal and the date of the order Required Documents Entry Fee Paid No Fees Required Fees, Costs, and Security waived by Judge (enter Judge's name belowTo be filed with the Appellate Clerk within ten days of the filing of the appeal, if applicable. See Practice Book Section 63-4.4. Statement for Preargument Conference (form JD-SC-28A) 5. Constitutionality Notice 6. Sealing Order form, if any I certify that a copy of the appeal form I am filing will immediately be delivered to each other counsel of record and I have included their names, addresses, e-mail addresses and telephone numbers; the appeal form has been redacted or does not contain any names or other personal identifying information that is prohibited from disclosure by rule, statute, court order or case law; and the appeal form complies with all applicable rules of appellate procedure in accordance with Practice Book Sections 62-7 and 63-3. Date to be delivered . If you have an exemption from e-filing under Practice Book Section 60-8, attach a list with the name, address, e-mail address, and telephone number of each counsel of record and the address where the copy was delivered. If this appeal is a criminal or habeas corpus matter, I certify that a copy of this appeal form will immediately be delivered to the Office of the Chief State222s Attorney Appellate Bureau. Date to be delivered .Date signed Date waived Judge American LegalNet, Inc. www.FormsWorkFlow.com