UNITED STATES DISTRICT COURT Form 3WESTERN DISTRICT OF NEW YORK , Plaintiff, M OTION FOR AN EXTENSION OF TIME v. TO FILE A NOTICE OF APPEAL , ________-CV-_________ Defendant(s). Notice is hereby given that, in the event the attached Notice of Appeal was not received in the Office of the Clerk of the Court within the required time, _________________________ [identify yourself as plaintiff or defendant in the district court action] respectfully requests the Courtto grant an extension of time in accordance with Fed.R.App.P. 4(a)(6). In support of this request, I state under penalty of perjury that this Courts decision was received on __________________ [date], and that this notice of appeal and motion were mailed to the Court on ___________________ [date]. Dated: _________________, 20___ Signature Print Your Name Appearing Pro Se Address: _______________________________________ _______________________________________ Telephone: _____________________________________