NOTICE OF APPEAL FROM TRIAL COURT Pursuant to Rule 5A:6, Rules of the Supreme Court of Virginia VIRGINIA: IN THE CIRCUIT COURT OF ............................................................................................................................................................................................ COUNTY/CITY ................................................................................................................................................ v. .......................................................................................................................... ........................................................................................................................... PLAINTIFF, RESPONDENT OR OTHER DESIGNATION IN TRIAL COURT .................................................................................................................................................................., NAME(S) OF PARTY(IES) hereby appeals to the Court of Appeals of Virginia from the ........................................................................................................................................................ FINAL JUDGMENT / APPEALABLE ORDER OR DECREE of this court entered on....................................... in case no(s) ............................................................................................. DATE Please check if: [ ] this is a termination of parental rights case (Va. Code §16.1-283, §16.1-277.01, §16.1-277.02 or §16.1-278.3). [ ] a transcript will be filed. [ ] a statement of facts, testimony, and other incidents of the case will be filed. CERTIFICATE The undersigned certifies as follows: (1) The name(s) and address(es) of appellant(s) are: ........................................................................................................................................................................................................................................................................................ [ ] Appellant(s), is (are) not represented by counsel. His/her telephone number(s) is (are): ........................................................................................................................................................................................................................................................................................ (2) The name(s), address(es) and telephone number(s) of counsel for appellant(s) is (are): ........................................................................................................................................................................................................................................................................................ (3) The name(s) and address(es) of appellee(s) is (are): ........................................................................................................................................................................................................................................................................................ [ ] Appellee(s), is (are) not represented by counsel. His/her telephone number(s) is (are): ........................................................................................................................................................................................................................................................................................ (4) The name(s), address(es) and telephone number(s) of counsel for appellee(s) is (are): ........................................................................................................................................................................................................................................................................................ (5) The name(s), address(es) and telephone number(s) of the guardian ad litem for the child(ren) is (are): ........................................................................................................................................................................................................................................................................................ (6) [ ] Counsel for appellant, or appellant if not represented by counsel, has ordered from the court reporter who reported the case the transcript for filing as required by Rule 5A:8(a). (7) [In criminal and termination of parental rights cases:] Counsel for appellant has been [ ] appointed [ ] privately retained. (8) A copy of this Notice of Appeal has been mailed or delivered to all opposing counsel, and/or to unrepresented parties and the guardian ad litem, if applicable, and to the Clerk of the Court of Appeals this of ............................................................................... , ....................................... ............................................................. day . __________________________________________ (Signature of counsel or unrepresented party) FORM CC-1345 (MASTER) 11/11 American LegalNet, Inc. www.FormsWorkFlow.com