FAMILY COURT New York State Suprem e Cou rt Appellate Division, Third Judicial Department P.O. Box 7288, Capitol Station Albany, New York 12224 APP DIV. CASE NO. TITLE: MATTER OF FAMILY CT. DOCKET NO. Fill in the blank spaces pertinent to your application. Complete five (5) copies: mail one to the county attorney, one to your adversary and one to the Law Guardian; return the original, sworn to before a notary public, to this office together w ith a copy of the decision and order which you are appealing and a copy of your notice of appeal; and retain th e fifth copy for your records. NOTE: NO APPEAL LIES FROM A DECISION, OPINION OR MEMORANDUM OF A COURT OR JUDGE BUT ONLY FROM AN ORDER. You must, within the time period set forth in Family Court Act § 1113, file an original and two copies of a notice of appeal with the Clerk of the Family Court. In addition, you also serve a copy of the notice of appeal upon the county attorney, the attorney for your adversary and, where appropriate, the Law Guardian. 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 natu re thereof) II. (a) I am appe aling from an order of the Fa mily Cou rt, , which provides as follows: County, entered (b) Was a hearing had at which testimony was taken? (c) If so, give the date o r dates of such he arings. (d) Date the ord er appealed from was served upon you : (e) Have you filed an original and two copies of the notice of appeal with Clerk of Family Court? When? (f) Have you served a copy of the notice of appeal on the County Attorney? (g) Have you served a copy of the notice of appeal on your adversary's attorney? Attorney's name and ad dress: When? 2002 © American LegalNet, Inc. (h) Have you served a copy of the notice of appeal on the Law Guardian? Law Guard ian's name and address: (i) Were you represented by counsel in Family Court? Counsel's name and address: (j) Dated: Was counsel assigned or retained? (Your signature) _________________________________________ _________________________________________ _________________________________________ _________________________________________ (Print your name, address and telephone 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 same are true to the best of my knowledge and belief. On the day of , 200 I served a true copy of this application by mailing the same in a sealed envelope, with postage prepaid thereon, in a pos t-office or official depository of the U.S. Pos tal Service within the State of New York, addressed to the last known addressee(s) as indicated below:1 (The County Attorney, the attorney for my adversary and the Law Guardian) _________________________________________ Signature (Print name below signature) Sworn to before me this _______________ day of ______________________, ________ _______________________________________ Notary Public (Revised 10-21-99) Insert names and addresses of the person(s) to whom you are mailing the papers being filed with this court. Please note that you must serve the County Attorney, the opposing party(ies) or their attorney(s) and the Law Guardian, if any. 2002 © American LegalNet, Inc. 1