FC-67 (revised April 2018) STATE OF RHODE ISLAND ANDPROVIDENCE PLANTATIONS FAMILY COURT NOTICE OF APPEAL Plaintiff /Petitioner Civil Action File Number Defendant /Respondent Name of Each Party and Attorney Filing Appeal Date Case First Filed in the Family Court Date of Judgment or Order Appealed From Party Filing Appeal Plaintiff (s) Petitioner(s) Defendant (s) Respondent(s) Other: Trial Court Judge TRIAL COURT ACTION APPEALED IPR Preliminary Injunction CJJ Judgment/Judge DPC Denial Post Conviction CON Conviction C DV Directed Verdict MTR Denial Sentence Reduction IPT Permanent Injunction CJU Judgment/Jury DCF Dependency/Termination CJD Default Judgment DAL Alimony DSJ S ummary Judgment CDS Dismissal/Jurisdiction PRO Probation Violation ASF Agreed Statement of Facts CDM Dismissal Merits PTM Pretrial Motion DRP Original Divorce Petition CTD New Trial Motion Denied FCJ Juvenile CUS Custody CTG New Trial Motion Granted PCR Grant Post Conviction JUDGMENT FOR: SENTENCES: Plaintiff(s) Confinement Suspended Defendant(s) Special Program Probation Other Fine/Restitution Deferred BAIL/RELEASE STATUS Personal Recognizance Surety Bond Held In Lieu Of Bail Held Without Bail Cash Bond Other TRANSCRIPT STATUS Transcript Will Not Be Ordered Filing Fee Required: Yes No Trial Court Receipt Number Transcript Will Be Ordered Appeal Filing Fee for Each Appellant or Petitioner: $ 170.75 for appellant; $150.00 for appellee /s/ Attorney for the Plaintiff /Petitioner the Defendant/Respondent or the Plaintiff /Petitioner the Defendant/Respondent Rhode Island Bar Number: Date: Telephone Number: American LegalNet, Inc. www.FormsWorkFlow.com