DISTRICT COURT OF MARYLAND FOR Located at Court Address City/County Case No. vs. STATE OF MARYLAND Defendant Address City, State, Zip Telephone NOTICE OF APPEAL The Defendant appeals the decision in this case to the proper appellate court. The Defendant requests the Court to waive court costs because he is unable to afford the expenses as will more fully appear in an attached financial statement and statement of earnings. I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information, and belief. Date Signature of Defendant/Defendant's Attorney Printed Name Address City, State, Zip Telephone E-mail Fax Check if applicable: I hereby certify that I am an attorney with the Public Defender's Office. assigned by Legal Aid Bureau, Inc. assigned by other legal services organization that accepts as clients only those persons meeting the financial eligibility criteria established by the Federal Legal Services Corporation or other appropriate governmental agency. Signature CERTIFICATE OF SERVICE I certify that I served a copy of this notice upon the following party or parties by first-class mail, postage prepaid on to: Date Name Name hand delivery mailing Address Address Date Signature of Party Serving DC-CR-017 (Rev. 05/2015) American LegalNet, Inc. www.FormsWorkFlow.com