New York State , Suprem e Cou rt Appellate Division, Third Department P.O. Box 7288, Capitol Station Alban y, New York HABEAS CORPUS: CASE #: INDEX #: Date of B irth: v. TITLE: PEOPL E ex rel. Fill in the blank spaces pertinent to your application. Com plete three copies: m ail one to the Attorney General (NYS Attorney General, The Capitol, Albany, NY 12224); return the original, sworn to before a notary p ublic, to this office together with a copy of the decision and judgmen t which you are appealing; an d retain the third cop y for your reco rds. NOTE: NO APPEAL LIES FROM A DECISION, OPINION OR MEMORANDUM OF A COURT OR JUSTICE BUT ONLY FROM A JU DGMEN T OR ORDE R. You must, w ithin 30 days from 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) (b) (c) II. Permission to appeal as a poor person Assign ment o f counse l Other relief (state nature thereof) I am appealing from: (a) (b) (c) A judgment deny ing my petition for a writ of habeas corpus A judgment dismissing a writ of habeas corpus after a hearing State nature of any other order or judgment appealed from Court to w hich you app lied for relief Was a hearing had at which testimony was taken If so, give the date or dates of such hearings Has an order or judgment denying relief been entered in the County Clerk's office If so, when (e) Has a copy of that order or judgment been served upon you If so, when III. (a) (b) (c) (d) 2002 © American LegalNet, Inc. -2(f) (g) (h) Have you filed a copy of the notice of appeal in the County Clerk's office If yes, when Have y ou serve d a copy of the notic e of appe al on the A ttorney G eneral If yes, when Were you rep resented by coun sel Counsel's name and address: (i) Was counsel assigned or retained Appellant's Signature Print Name: Address: ID Num ber: STATE OF NEW YORK COUNTY OF ) ) ss.: , being duly sworn, says that I have read the foregoing answers and the same are true to the best of my knowledge and belief. On the , day of , ,I mailed a completed copy of this form to the Attorney General. Appellant's Signature Print Name Sworn to me this of , day . Notary Pub lic FORM REVISED 3-2-98 2002 © American LegalNet, Inc.