STATE OF GEORGIA

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In the interest of:    | Case number 123456

                       | Judge_______________

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AFFIDAVIT

I hereby certify that I am the ________________County, Georgia, and that I was appointed by the trial court to represent the defendant-appellant because of indigence. Defendant is incarcerated and remains indigent and unable to pay the costs of appeal.

Attorney for Defendant-Appellant

Sworn to and subscribed before me this day of ____________, 1995.

NOTARY PUBLIC, STATE AT LARGE

CERTIFICATE OF SERVICE

This is to certify that I have this day served opposing counsel, , District Attorney, or a member of his staff, a copy of the foregoing pleading by hand delivery at the County District Attorney's Office, County Courthouse, ______________, Georgia.

This _____________ day of __________________, 1995.

IN THE SUPERIOR COURT OF COUNTY

STATE OF GEORGIA

STATE OF GEORGIA       ]

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vs.                    ] CASE NO.

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Defendant.             ]

NOTICE OF APPEAL

Defendant hereby files this his Notice of Appeal to the Court of Appeals of Georgia from the judgement and sentence entered on .

Defendant was sentenced to ___________. Restitution estimated at $_________ was made a part of the sentence. Restitution hearing was held on and restitution of $________ was imposed. Order was also entered on _________.

The Clerk will please omit nothing from the record on appeal. Transcript of evidence and proceedings have been transcribed and are to be filed for inclusion in the record on appeal.

The Court of Appeals of Georgia has jurisdiction of this case for the reason that the judgement of conviction and sentence was entered on a non-capital felony. Art. VI, Sec. V, Par. III of the 1983 Constitution of Georgia.

This day of January, 1995.

CERTIFICATE OF SERVICE

This is to certify that I have this day served opposing counsel, , District Attorney, or a member of his staff, a copy of the foregoing pleading by hand delivery at the County District Attorney's Office, County Courthouse, _______________, Georgia.

This _____________ day of __________________, 1995.