Commonwealth of Pennsylvania Court of Common Pleas County of: Judicial District Appellant Name: Address: City: State: Zip: Date: Citation No: Magisterial District No: Issuing Authority Docket Number: Notice of Appeal from Summary Criminal Conviction A sentence of was imposed on: . Offense(s) of which convicted: Grounds relied upon for appeal (except when the appeal is from a guilty plea or a conviction): Date of entry of guilty plea, the conviction, or other final order from which appeal is taken: Name and mailing address of affiant as show on citation or complaint: Affiant Name: Address: City: State: Zip: If sentence includes fines, costs or restitution, amount paid, if any: Type or amount of bail or collateral furnished to issuing authority, if any: Name and mailing address of issuing authority: Issuing Authority: Address: City: Phone No: State: Zip: Name and address of attorney filing notice of appeal: Attorney Signature: Attorney Name (Printed): Address: City: Phone No: Supreme Court ID Number: State: Fax No: Zip: NOTICE TO DEFENDANT: If your appeal is from a motor vehicle conviction other than parking, have the clerk of courts certify this copy and mail to the following address: PennDOT Correspondence Unit PO Box 68618 Harrisburg, PA 17106 I hereby certify that an appeal has been filed in the above-captioned case. Clerk of Courts AOPC 2026 American LegalNet, Inc. www.FormsWorkFlow.com