Allegany County DISTRICT COURT OF MARYLAND FOR ....................................................................................................
City/County
Located at .................................................................................Case No. ......................................................................
Court Address
STATE OF MARYLAND
vs.
...........................................................................................
Defendant
........................................................................................... Address ...........................................................................................
Telephone
NOTICE OF APPEAL
Please enter an appeal to the proper appellate court from the judgment in the case named above. THE DEFENDANT requests the Court to waive court costs because he is unable to afford the expenses as will more fully appear in an attached financial statement and statement of earnings. I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information and belief.
...........................................................................................
Date
...........................................................................................
Signature of Defendant/State's Attorney Printed Name
........................................................................................... ...........................................................................................
Address
...........................................................................................
Telephone
Reset Form
Check if applicable: I hereby certify that I am an attorney
o with the Public Defender's Office. o assigned by Legal Aid Bureau, Inc. o assigned by other legal services organization that
accepts as clients only those persons meeting the financial eligibility criteria established by the Federal Legal Services Corporation or other appropriate governmental agency.
Signature
____________________________________________
DC/CR 17 (Rev. 6/2003)