NOTICE OF APPEAL., Defendant/Appellant appeals to the Fourth. District Court of Appeal the judgment and sentence entered by the Honorable,

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1 IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT OF FLORIDA, IN AND FOR PALM BEACH COUNTY. CRIMINAL DIVISION: CASE NO: Plaintiff/Appellee, Defendant/Appellant / NOTICE OF APPEAL NOTICE IS GIVEN that, Defendant/Appellant appeals to the Fourth District Court of Appeal the judgment and sentence entered by the Honorable, of the Circuit Court of the Fifteenth Judicial Circuit, in and for Palm Beach County, Criminal Division, rendered on this day of, 20. A sentence of has been imposed and the Defendant/Appellant in custody. Respectfully submitted, BY:

2 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Notice of Appeal has been furnished by hand delivery, or mail, to the Office of the State Attorney, Criminal Justice Building, 401 N. Dixie Highway, West Palm Beach, Florida, and the Office of the Attorney General, 1515 North Flagler Drive, 9 th Floor, West Palm Beach, Florida , this day of, 20. Of Counsel.

3 IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT, IN AND FOR PALM BEACH COUNTY, FLORIDA DIVISION: Case No.: Defendant/Appellant. / ORDER OF INSOLVENCY AND APPOINTMENT OF APPELLATE COUNSEL Upon a determination of indigent status and upon the Defendant s request for an appeal or the Defendant s filing of the Notice of Appeal, it is: ORDERED AND ADJUDGED that the Defendant/Appellant is hereby declared insolvent and indigent for the purposes of this appeal in accordance with the provisions of Fla. R. Crim. P , Fla. R. App. P and section , Florida Statutes, and it is further ORDERED AND ADJUDGED that all costs incident to this appeal shall be paid by the Statewide-contracted, Due Process Services/Appropriations, Justice Administration Commission of the State of Florida and it is further ORDERED AND ADJUDGED that the Office of the Public Defender is hereby appointed to represent the said Defendant/Appellant for purposes of appeal. DONE AND ORDERED this day of, 20, in Chambers, Palm Beach County, Florida. JUDGE, CIRCUIT COURT

4 Copies furnished: Trial Attorney Public Defender - Appellate Division; Attorney General s Office; State Attorney s Office; Justice Administration Commission, P. O. Box 1654, Tallahassee, Florida 32302

5 IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT OF FLORIDA, IN AND FOR PALM BEACH COUNTY. CRIMINAL DIVISION: CASE NO: Plaintiff/Appellee, Defendant/Appellant. / DESIGNATION TO COURT REPORTER Defendant/Appellant, files this designation to the manager of the Official Court Reporters, and directs the court reporter to transcribe an original and two copies of the following to be filed with the clerk s office of the lower tribunal: [TRIAL ATTORNEYS MUST SPECIFY ALL NECESSARY HEARINGS AND DATES HERE] I, Counsel for Defendant/Appellant, certify that satisfactory financial arrangements have been made with the court reporter for preparation of the transcripts since the defendant is indigent and the Office of the Justice Administration Commission due process appropriation fund will bear that cost. Respectfully submitted,

6 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the Designation to Court Reporter has been furnished to the Office of the State Attorney, Criminal Justice Building, 401 North Dixie Highway, West Palm Beach, Florida; the Office of the Attorney General, 1515 North Flagler Drive, 9 th Floor, West Palm Beach, Florida ; and Susan Wiggins, Manager, Official Court Reporters, Room , Palm Beach County Courthouse, 205 N. Dixie Highway, West Palm Beach, Florida, this day of, 20.

7 IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT, IN AND FOR PALM BEACH COUNTY, FLORIDA CRIMINAL DIVISION: Plaintiff/Appellee, CASE NO: Defendant/Appellant / STATEMENT OF JUDICIAL ACTS TO BE REVIEWED The Defendant/Appellant files the following statement of judicial acts to be reviewed: 1. Respectfully submitted, Florida Bar No: CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Statement of Judicial Acts hereof has been furnished by courier to, this day of.

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