APPEALED ARTICLE 78 New York State Supreme Court Appellate Division, Third Judicial Department P.O. Box 7288, Capitol Station Albany, New York 12224 App Div. Case No. _______ Supreme Ct. Index No. Date of Birth ________ TITLE: MA TTE R O F __________________________________________________ Fill in the blank spaces pertinent to your application. Complete three (3) copies: mail one to the Attorney General (NYS Attorney General, The Capitol, Albany, NY 12224); return the original, sworn to before a notary public, to this office together with a copy of the decision and judgment which you are appealing; and retain the third copy for your records. NOTE: NO APPEAL LIES FROM A DECISION, OPINION OR MEMORANDUM OF A COURT OR JUDGE BUT ONLY FROM A JUDGMENT OR ORDER. You must, 30 days fromn the date of the judgment or order you are appealing, serve a notice of appeal upon the Attorney General and file a copy of such notice with the County Clerk of the county in which the judgment or order was entered. I. My present application is for: (a) Permission to appeal as a poor person (b) Assignment of counsel (c) Extension of time to perfect appeal (d) Other relief (state nature thereof) II. (a) I am appealing from a judgment of the Supreme Court of _________ County entered ________________, which provides as follows: III. (a) Court to which you applied for relief ___________________________ (b) Was a hearing had at which testimony was taken _________________ (c) If so, give the date or dates of such hearings ____________________ ________________________________________________________ (d) Has an order or judgment denying relief been entered in the County Clerk's Office ______ If so, when _____________________ 2002 © American LegalNet, Inc. (e) Has a copy of that order or judgment been served upon you ___ if so, when _________ (f) Have you filed a copy of the notice of appeal in the County Clerk's office, If yes, when ____________________________ (g) Have you served a copy of the notice of appeal on the Attorney General If yes, when ____________________________ (h) Were you represented by counsel ________________________________ Counsel's name and address: __________________________ __________________________ __________________________ (i) Was counsel assigned or retained __________________________ ____________________________ Signature Print Name & Address: ____________________________ ____________________________ ____________________________ Id Number: ____________________________ ATTACH A COPY Of THE NOTICE OF APPEAL and ORDER APPEALED FROM STATE OF NEW YORK ) COUNTY OF _____________________) ss. ___________________________________, being duly sworn, says: I have read the foregoing answers and the sam are true to the best e of my know ledge and belief. On the Attorney General. ____________________________________ Sign ature day of , I mailed a com pleted copy of this form to the Sworn to before me this _______day of ______________________, _____. _______________________________ Notary Public (Revised 9-18-01) 2002 © American LegalNet, Inc.