Free cc265.pmd - Michigan

Approved, SCAO

Original - Trial court 1st copy - Prosecutor 2nd copy - Defendant/Juvenile for return 3rd copy - Defendant/Juvenile

STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
Court address

NOTICE OF RIGHT TO APPELLATE REVIEW AND REQUEST FOR APPOINTMENT OF ATTORNEY Judge:

CASE NO.

Court telephone no.

Defendant/Juvenile name, address, telephone no., and date of birth

THE PEOPLE OF THE STATE OF MICHIGAN

v

NOTICE OF RIGHT TO APPELLATE REVIEW Note to court: This notice must be given to the defendant/juvenile at sentencing. 1. You are entitled to appellate review of your conviction and sentence. This is done by filing a claim of appeal by right, or when you are not entitled to file a claim of appeal by right, an application for leave to appeal. If you pled guilty or nolo contendere, an appeal must be done by filing an application for leave to appeal. 2. Whether you appeal by right or apply for leave to appeal, if you cannot afford to hire an attorney to represent you on appeal and you request an attorney, the court will appoint an attorney and furnish the attorney with the portions of the transcript and record that the attorney needs. 3. A request for the appointment of an attorney must be made in writing and sent directly to the court at the address noted above within 42 days. The financial schedule on the back of this form must be completed.

RECEIPT OF NOTICE OF APPEAL RIGHTS On this day I received this form and financial schedule. I understand that I must return the completed Request for Appointment of Attorney to the court within 42 days if I want an attorney appointed for my appeal.

Date

Signature of defendant/juvenile

REQUEST FOR APPOINTMENT OF ATTORNEY AND AFFIDAVIT OF INDIGENCY I request appointment of an attorney to appeal my conviction. If applicable, conditions for my request are on the back of this form. The affidavit of indigency and financial schedule on the back of this form is submitted to show my financial condition.

Date

Signature of defendant/juvenile

NOTE TO DEFENDANT/JUVENILE: After completing the request for appointment of attorney and the affidavit of indigency and financial schedule, keep one copy for yourself and return the other copy to the court.

MCR 6.425(F) CC 265 (3/09)

NOTICE OF RIGHT TO APPELLATE REVIEW AND REQUEST FOR APPOINTMENT OF ATTORNEY

AFFIDAVIT OF INDIGENCY AND FINANCIAL SCHEDULE I request a court-appointed attorney and submit the following information:
1. RESIDENCE Rent 2. MARITAL STATUS Single 3. INCOME Married Divorced Separated
b. Length of employment

Own

Live with parents

Room/Board

Prison
Number

Dependents:
Number

a. Employer name and address

c. Average pay

weekly Gross: $

monthly Net: $

every two weeks

d. Other income (state monthly amount and source [DHS, VA, rent, pensions, spouse, unemployment, etc.]) If no income, state NONE.

4. ASSETS

State value of car, home, bank deposits, inmate accounts, bonds, stocks, etc. If no assets, state NONE. Attach an account statement and certification for assets in prison accounts.

5. OBLIGATIONS

Itemize monthly rent, installment payments, mortgage payments, child support, etc.

Signature Name (type or print) Address City, state, zip

Subscribed and sworn to before me on
Date

, Signature:
Notary public

County, Michigan

My commission expires:
Date

Notary public, State of Michigan, County of