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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)