SUPREME COURT OF THE STATE OF NEW YORK APPELLATE DIVISION, THIRD DEPARTMENT ---------------------------------------------------------------------x STATEMENT OF E-FILING Appellate Division Case/Docket No.: -against- Originating Court No.: Date Notice of Appeal Filed: // ---------------------------------------------------------------------x PLEASE TAKE NOTICE: Statement of prior E-Filing (appellant): [ ] I,, am [ ] an attorney in good standing representing a party in the above-captioned action, [ ] an attorney admitted pro hac vice representing a party in this matter, or [ ] a self-represented party in this matter, and hereby certify under penalty of perjury that the above matter was electronically filed through the New York State Courts court of original instance. I understand that this matter must be perfected through the NYSCEF system, and am aware of the rights and responsibilities of parties (including unrepresented parties) under the Appellate Divisions e-filing rules (22 NYCRR Part 1245). Additionally, I understand that once an appellate number is assigned, I must serve this Statement of E-Filing together with Notification of Case Number (AD-EF-01) in accordance with Appellate Division e-filing rules, as supplemented by local rules. OR Stipulation and consent of parties: [ ] We the undersigned, counsel in good standing representing parties, counsel admitted pro hac vice, and/or an unrepresented party in this matter, hereby stipulate and consent in this matter. We agree to be bound by Appellate Division e-filing rules (22 NYCRR Part 1245), as supplemented by local court rules. The undersigned confirm that they are registered as authorized e-filers with NYSCEF and understand that the primary e-mail addresses, listed below, will be used for service of documents. 1 American LegalNet, Inc. www.FormsWorkFlow.com Dated: Attorney [ ] Pro Hac [ ] Unrep [ ] Attorney [ ] Pro Hac [ ] Unrep [ ] Signature Signature Print Name Print Name Attorney for (Identity of Parties) Attorney for (Identity of Parties) UCS Attorney Registration # UCS Attorney Registration # Firm Name Firm Name Address Address Phone # Phone # E-Mail E-Mail (Primary Service E-Mail Address) (Primary Service E-Mail Address) Attorney [ ] Pro Hac [ ] Unrep [ ] Attorney [ ] Pro Hac [ ] Unrep [ ] Signature Signature Print Name Print Name Attorney for (Identity of Parties) Attorney for (Identity of Parties) UCS Attorney Registration # UCS Attorney Registration # Firm Name Firm Name Address Address Phone # Phone # E-Mail E-Mail (Primary Service E-Mail Address) (Primary Service E-Mail Address) 2 American LegalNet, Inc. www.FormsWorkFlow.com