SUPREME COURT OF THE STATE OF NEW YORK APPELLATE DIVISION FOURTH DEPARTMENT ______________________________________________ In the Matter of ________________ Respondent/Appellant, STATEMENT OF WITHDRAWAL _____________________________________________ _________ Petitioner/Respondent. ______________________________________________ STATE OF NEW YORK ) ) ss.: COUNTY OF____________ ) 1. 2. I am the appellant,___________, named in the above-entitled appeal from an After due deliberation and consideration, I hereby request my notice of appeal, Docket No.: Order of ____________ of the _____________ County Family Court. dated the _____day of ______, 2____, and filed in the Office of the _____________ County Family Court the ___ day of _____, 2____, be withdrawn; I do not intend to pursue this appeal. 3. I make this free and voluntary decision after consultation with my attorney, _______________, Esq., who has advised me of my rights, and the merits of an appeal from a Family Court Fact-finding Order entered upon Stipulation and Consent, and a Dispositional Order following a full Disposition Hearing in which I was represented by competent counsel. Said Order of Fact-Finding and Disposition was entered in the Office of the Family Court Clerk on the________ day of _______, 2____. I am satisfied with the legal services provided to me on this matter and am not requesting the Appellate Division assign another counsel for me. 4. No one has made me any promises or offered me anything of value to induce me to withdraw my appeal. I am not under any duress or coercion and this is a knowing and voluntary decision on my part. 5. Dated: No prior relief has been requested. _________, New York. ___________________ 2002 © American LegalNet, Inc. ___________________________ STATE OF NEW YORK COUNTY OF On this day of ) ) ss.: ) , in the year 2 before me, the undersigned, a Notary Public in , personally known to me or proved to and for said State, personally appeared me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within Instrument and acknowledged to me that she executed the same in her capacity, and that by her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. ___________________________ Notary Public 2002 © American LegalNet, Inc.