IN THE COURT OF COMMON PLEAS, COUNTY OF NORTHAMPTON Notice of Appeal from Summary Criminal Conviction Name and Address of Defendant: Date ____________________ __________________________________________________ __________________________________________ __________________________________________ Date of Birth _______________________________________ Docket No. _______________________________________________ Citation No. _______________________________________________ Magisterial District No. _____________________________________ Appeal from Sentence of: ___COSTS & FINES_________________________________________________________ Date of Sentence: ________________ Offense(s) of which convicted ______________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Name and Mailing Address of Police Officer/Accuser as shown on Citation or Complaint: ___________________________________________________ If sentence includes fine and costs, amount of which paid: _________________________________________________________ Type or amount of bail furnished to issuing authority, if any: ___________________________________________________ _________________________________________________________ ___________________________________________________ Name and address of Magisterial District Judge: ___________________________________________________ Name and Address of Attorney for Defendant: Attorney Identification No. (Signature) _______________________________________________ ___________________________________________________ (Print Name)______________________________________________ ___________________________________________________ (Address) ________________________________________________ Magisterial District No. ________________________________ _____________________________(Phone) _____________________ Clerk of Courts (White) Defendant's Copy (Green) Magisterial District Justice (Yellow) District Attorney (Pink) Affiant's Copy (Golden Rod) American LegalNet, Inc. www.FormsWorkFlow.com