NEW YORK STATE COURT OF APPEALS Preliminary Appeal Statement Pursuant to section 500.9 of the Rules of the Court of Appeals 1. CAPTION OF CASE (as the parties should be denominated in the Court of Appeals): STATE OF NEW YORK COURT OF APPEALS -against- [ Attach additional sheets if further space is required ] ______________________________________________________ 2. Name of court or tribunal where case originated, including county, if applicable: ____________________________________________________________________ 3. Civil index number, criminal indictment number or other number assigned to the matter in the court or tribunal of original instance:____________________ 4. Docket number assigned to the matter at the Appellate Division or other intermediate appellate court:_____________________ 5. Jurisdictional basis for this appeal: ____Leave to appeal granted by the Court of Appeals or a Judge of the Court of Appeals ____Leave to appeal granted by the Appellate Division or a Justice of the Appellate Division ____CPLR 5601(a): dissents on the law at the Appellate Division ____CPLR 5601(b)(1): constitutional ground (Appellate Division order) ____CPLR 5601(b)(2): constitutional ground (judgment of court of original instance) ____CPLR 5601(c): Appellate Division order granting a new trial or hearing, upon stipulation for judgment absolute ____CPLR 5601(d): from a final judgment, order, determination or award, seeking review of a prior nonfinal Appellate Division order ____Other (specify)_____________________________________________________ 6. How this appeal was taken to the Court of Appeals (choose one) (see CPLR 5515[1]): American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF APPEAL Date filed:________________________ Clerk's office where filed:_________________ ORDER GRANTING LEAVE TO APPEAL (civil case): Court that issued order:______________ Date of order:_________________ CERTIFICATE OR ORDER GRANTING LEAVE TO APPEAL (criminal case): Justice or Judge who issued order:_______________ Court:________________ Date of order:__________________ 7. Demonstration of timeliness of appeal in civil case (CPLR 5513, 5514): Was appellant served by its adversary with a copy of the order, judgment or determination appealed from and notice of its entry? ___yes ___no If yes, date on which appellant was served (if known, or discernable from the papers served): __________________ If yes, method by which appellant was served: ____personal delivery ____regular mail ____overnight courier ____other (describe___________) Did the Appellate Division grant or deny a motion for leave to appeal to this Court in this case? ____yes ____no If yes, fill in the following information: a. date appellant served the motion for leave to appeal made at the Appellate Division: ________________ b. date on which appellant was served with the Appellate Division order granting or denying such motion with notice of the order's entry: ________________________ , and c. method by which appellant was served with the Appellate Division order granting or denying such motion: _________________ personal service _________________ regular mail _________________ overnight courier _________________ other (describe __________) 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. Party Information: Instructions: Fill in the name of each party to the action or proceeding, one name per line. Indicate the status of the party in the court of original instance and the party's status in this Court, if any. Examples of a party's original status include: plaintiff, defendant, petitioner, respondent, claimant, third-party plaintiff, third-party defendant, intervenor. Examples of a party's Court of Appeals status include: appellant, respondent, appellant-respondent, respondent-appellant, intervenorappellant. No. 1 2 3 4 5 6 7 8 9 10 Party Name Original Status Court of Appeals Status 9. Attorney information: Instructions: For each party listed above, fill in the name of the one law firm and responsible attorney who will act as counsel of record, if the party is represented. Where a litigant is self-represented, fill in that party's data in section 10 below. For Party No. __ above: Law Firm Name:___________________________________________________________________________________ Responsible Attorney:_______________________________________________________________________________ Street Address:_____________________________________________________________________________________ City:________________________State:__________Zip:___________________________________________________ Telephone No:______________Ext._________________Fax:_______________________________________________ If appearing Pro Hac Vice, has attorney satisfied requirements of section 500.4 of the Rules of the Court of Appeals?___yes ____no For Party No. __ above: Law Firm Name: ___________________________________________________________________________________ Responsible Attorney:_______________________________________________________________________________ Street Address:_____________________________________________________________________________________ City:________________________State:__________Zip:___________________________________________________ Telephone No:______________Ext._________________Fax:_______________________________________________ If appearing Pro Hac Vice, has attorney satisfied requirements of section 500.4 of the Rules of the Court of Appeals?___yes ____no For Party No. __ above: Law Firm Name:___________________________________________________________________________________ Responsible Attorney:_______________________________________________________________________________ Street Address:_____________________________________________________________________________________ City:________________________State:__________Zip:___________________________________________________ Telephone No:______________Ext._________________Fax:_______________________________________________ If appearing Pro Hac Vice, has attorney satisfied requirements of section 500.4 of the Rules of the Court of Appeals?___yes ____no 3 American LegalNet, Inc. www.FormsWorkFlow.com For Party No. __ above: Law Firm Name:___________________________________________________________________________________ Responsible Attorney:_______________________________________________________________________________ Street Address:_______________________________________________________________________________