Revised 02/2019 IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY, PENNSYLVANIA Notice of Appeal from Summary Criminal Conviction Appeal from Installment Payment Plan Name and Address of Defendant: Telephone: Signature of Defendant/Attorney Magisterial District Justice Docket No. Citation No. Magisterial District Justice District (Please check one): District Court 36-1-01 Vacant, 650 11th Street, Ambridge, PA 15003 District Court 36-1-02 Dirk A. Goodwald, 1100 6th Avenue, Beaver Falls, PA 15010 District Court 36-2-02 Tim Finn, 175 Friendship Drive, Beaver, PA 15009 District Court 36-3-03 Joseph Schafer, 226-F Center Grange Road, Aliquippa, PA 15001 District Court 36-3-02 C. Douglas Loughner, 19 Cessna Drive, Beaver Falls, PA 15010 District Court 36-2-01 Edward C. Howe, 559 Third Street, Freedom, PA 15042 District Court 36-3-04 Janet Swihart, 1515 Gringo Road, Aliquippa, PA 15001 District Court 36-3-01 Dale Nicholson, 513 11th Street, New Brighton, PA 15066 Appeal from the sentence of: Guilty Guilty in Abstentia Other Date of Sentence: Date of Appeal: Charge(s) Appealing: Name and Address of Arresting Officer on Citation: Amount of Costs & Fines Paid at MDJ Type & Amount of Bail Furnished to MDJ Name and Address of Attorney of Defendant: Print Name: Supreme Court No. Print Address: NOTICE TO DEFENDANT: you may have the Clerk of Courts certify a copy of this appeal ($15.25 per certified copy) for your use in requesting a delay in your suspension to the Bureau of Driver Licensing. Request is to be sent to: PennDot Office of Chief Counsel, Vehicle & Traffic Law Division, 1101 South Front Street Third Floor, Harrisburg, PA 17104-2516. FEE TO FILE THIS APPEAL IS $127.00 AND IS NON-REFUNDABLE AND DUE AT TIME OF FILING. PLEASE NOTE THERE WILL BE COSTS IN ADDITION TO THOSE IMPOSED AT YOUR ORIGINAL SUMMARY HEARING BEFORE THE MAGISTERIAL DISTRICT JUDGE IF YOU ARE FOUND GUILTY OR PLEAD GUILTY. FURTHER, SHOULD YOU FAIL TO APPEAR AT THE TIME OF YOUR DE NOVO HEARING, THE COURT MAY DISMISS THE APPEAL AND ENTER JUDGMENT IN THE COURT OF COMMON PLEAS ON THE JUDGMENT OF THE ISSUING AUTHORITY. SHOULD YOU WITHDRAW YOUR APPEAL, THE TRIAL JUDGE SHALL ENTER JUDGMENT IN THE COURT OF COMMON PLEAS ON THE JUDGMENT OF THE ISSUING AUTHORITY. NO CHECKS ACCEPTED FOR FILING FEE I have read and understand American LegalNet, Inc. www.FormsWorkFlow.com