Appealed Article 78 (Application For Poor Person Relief Assignment Of Counsel And Or Extension Of Time To Perfect Appeal)

APPEALED ARTICLE 78 New York State Supreme Court Appellate Division, Third Judicial Department P.O. Box 7288, Capitol Station Albany, New York 12224 App Div. Case No. _______ Supreme Ct. Index No. Date of Birth ________ TITLE: MA TTE R O F __________________________________________________ Fill in the blank spaces pertinent to your application. Complete three (3) copies: mail one to the Attorney General (NYS Attorney General, The Capitol, Albany, NY 12224); return the original, sworn to before a notary public, to this office together with a copy of the decision and judgment which you are appealing; and retain the third copy for your records. NOTE: NO APPEAL LIES FROM A DECISION, OPINION OR MEMORANDUM OF A COURT OR JUDGE BUT ONLY FROM A JUDGMENT OR ORDER. You must, 30 days fromn the date of the judgment or order you are appealing, serve a notice of appeal upon the Attorney General and file a copy of such notice with the County Clerk of the county in which the judgment or order was entered. I. My present application is for: (a) Permission to appeal as a poor person (b) Assignment of counsel (c) Extension of time to perfect appeal (d) Other relief (state nature thereof) II. (a) I am appealing from a judgment of the Supreme Court of _________ County entered ________________, which provides as follows: III. (a) Court to which you applied for relief ___________________________ (b) Was a hearing had at which testimony was taken _________________ (c) If so, give the date or dates of such hearings ____________________ ________________________________________________________ (d) Has an order or judgment denying relief been entered in the County Clerk's Office ______ If so, when _____________________ 2002 © American LegalNet, Inc. (e) Has a copy of that order or judgment been served upon you ___ if so, when _________ (f) Have you filed a copy of the notice of appeal in the County Clerk's office, If yes, when ____________________________ (g) Have you served a copy of the notice of appeal on the Attorney General If yes, when ____________________________ (h) Were you represented by counsel ________________________________ Counsel's name and address: __________________________ __________________________ __________________________ (i) Was counsel assigned or retained __________________________ ____________________________ Signature Print Name & Address: ____________________________ ____________________________ ____________________________ Id Number: ____________________________ ATTACH A COPY Of THE NOTICE OF APPEAL and ORDER APPEALED FROM STATE OF NEW YORK ) COUNTY OF _____________________) ss. ___________________________________, being duly sworn, says: I have read the foregoing answers and the sam are true to the best e of my know ledge and belief. On the Attorney General. ____________________________________ Sign ature day of , I mailed a com pleted copy of this form to the Sworn to before me this _______day of ______________________, _____. _______________________________ Notary Public (Revised 9-18-01) 2002 © American LegalNet, Inc.