NOTICE OF APPEAL TO APPELLATE DIVISION, THIRD DEPARTMENT FROM CRIMINAL CONVICTION STATE OF NEW YORK COURT COUNTY OF THE PEOPLE OF THE STATE OF NEW YORK, NOTICE OF APPEAL Indictment/SCI No.: v , Defendant . PLEASE TAKE NOTICE that the defendant hereby appeals to the Supreme Court, Appellate Division, Third Judicial Department, from the judgment of conviction and sentence rendered in Court, County, on , 20 , and from each and every part thereof and from each and every intermediate order made therein. Dated: (Signature) (Print Name) (Address) (Telephone) TO: (File 2 Copies with Clerk of Court where Convicted) (Name and address of District Attorney of County of Conviction) Revised: February 19, 2014 American LegalNet, Inc. www.FormsWorkFlow.com