PRE-CALENDAR STATEMENT State of New York Supreme Court - Appellate Division Third Judicial Department Case Title: Set forth the full case title. County Index No. RJI No. Date of Commencement Parties Involved: Set forth the full names of the original parties and any change in parties. Party Name Original Status Appellate Status (eg. John Doe) (eg. Defendant) (eg. Appellant) Counsel for Appellant(s):Set forth the name, address, telephone number and facsimile telephone num ber of counsel for appellant(s). Counsel for Respondent(s) and Counsel for Other Parties: Set forth the name, address, telephone number and facsimile telephone number of counsel for respondent(s) and for each other party. 2002 © American LegalNet, Inc. Court, Judge and County: Identify the court, judge or justice, and the county from which the appeal is taken. Nature and Object of Action or Proceeding: Concisely set forth the nature and object of the underlying action or proceeding. Appellate Issue(s): Set forth a clear and concise statement of the issue(s) to be raised on the appeal, the grounds for reversal or modification to be advanced and the specific relief sought on the appeal. Other Related Matters: Indicate if there is another related action or proceeding, identifying and briefly describing same. Submitted by: Signature Print Name: Attorney for: Date: 2002 © American LegalNet, Inc. Attachments: Check 1. Copy of order or judgment appealed from. attached 2. Copy of opinion or decision. attached does not exist 3. Copy of notice of appeal or order granting leave to appeal. attached Attach copies, not originals. File this original form with attachments when original notice of appeal is filed in the office where the judgment or order of court of original instance is entered. A copy of this document must be served upon all counsel and pro se parties. (effective 11/12/97). 2002 © American LegalNet, Inc.