1 of 3 CIVIL PROCEDURE FORM NO. 8-A(3) IN THE JUDICIAL CIRCUIT, COUNTY, MISSOURI Judge or Division: Circuit Court Case Number: (Date File Stamp) Plaintiff/Petitioner: Appellate Number: Filing as an Indigent Date of Judgment /Sentence /Order : (ATTACH A COPY) Court Reporter: vs. Date Post Trial Motion Filed: Sound Recording Equipment Defendant/Respondent: Date Ruled Upon: The Record on Appeal will consist of: Legal File only or Legal File and Transcript Notice of Appeal to Missouri Court of Appeals - Criminal District: Western Eastern Southern Notice is given that appeals from the judgment/sentence/order entered in this action on (date). Appellant222s Name Respondent222s Name Address Address Telephone Telephone Appellant222s Attorney/Bar Number (If multiple, list all or attach additional pages) Respondent222s Attorney/Bar Number (If multiple, list all or attach additional pages) Address Address E - mail Address E - mail Add ress Telephone Telephone DOC Register Number (If applicable) Charges and Sentences Imposed Does this appeal involve a felony conviction? Yes No Has the defendant been released on an appeal bond? Yes (ATTACH BOND) No Bond Amount Surety Name, Address, and Phone Number American LegalNet, Inc. www.FormsWorkFlow.com 2 of 3 Docket Fee Information The docket fee in the amount of $70.00 is being tendered with this notice of appeal. No docket fee is being tendered because: a docket fee is not required by law pursuant to (cite specific statute or other authority). a motion to prosecute the appeal in forma pauperis has been or will be filed. a docket fee in the amount of $70.00 cannot be tendered at this time but will be submitted at a later date or this appeal will be subject to dismissal pursuant to Rule 84.08(a). Signature of Attorney or Appellant Date Certificate of Service on Persons other than Registered Users of the Missouri eFiling System I certify that on (date), a copy of the foregoing was sent to the following by facsimile, hand-delivery, electronic mail or U.S. mail postage prepaid to their last known addresses. Appellant or Attorney for Appellant Directions to Clerk As required by Rule 30.01(c), a copy of the notice of appeal shall be sent by the clerk to the Attorney General when the appeal involves a felony. Transmit a copy of the notice of appeal and all attached documents to the clerk of the Court of Appeals and to any person other than registered users of the eFiling system in a manner prescribed by Rule 43.01. Clerk shall then fill in the memorandum below. See Rule 81.08(i). Forward the docket fee to the Department of Revenue as required by statute. Memorandum of the Clerk I have this day served a copy of this notice by regular mail registered mail certified mail facsimile transmission to each of the following persons at the address stated below. If served by facsimile, include the time and date of transmission and the telephone number to which the document was transmitted. I have transmitted a copy of the notice of appeal to the clerk of the Court of Appeals, District. Docket fee in the amount of $70.00 was received by this clerk on (date) which will be disbursed as required by statute. No docket fee was received. Date Clerk American LegalNet, Inc. www.FormsWorkFlow.com 3 of 3 Additional Parties and Attorneys List every party involved in the case not listed on page 1, indicate the position of the party in the circuit court (e.g. plaintiff, defendant, intervenor) and in the Court of Appeals (e.g. appellant or respondent) and the name of the attorney of record, if any, for each party. Attach additional pages to identify all parties and attorneys if necessary. Party Name Attorney Name Address Address City, State, Zip Code City, State, Zip Code E-mail Address Telephone Party Name Attorney Name Address Address City, State, Zip Code City, State, Zip Code E-mail Address Telephone Party Name Attorney Name Address Address City, State, Zip Code City, State, Zip Code E-mail Address Telephone Party Name Attorney Name Address Address City, State, Zip Code City, State, Zip Code E-mail Address Telephone American LegalNet, Inc. www.FormsWorkFlow.com