(YOUR NAME)
(YOUR STREET ADDRESS)
(YOUR CITY/STATE/ZIP)
(YOUR PHONE NUMBER)
Appellant, In Propria Persona

                                   (NAME OF COURT WHERE
                     JUDGMENT/DECREE TO BE APPEALED WAS ENTERED)

               (CAPTION OF YOUR CASE; Edit to make it look similar to documents filed in your case)


_____________________________________) _____________________________________) No.
(CASE NUMBER OF CASE 
_____________________________________) IN WHICH JUDGMENT TO BE 
_____________________________________) APPEALED WAS ENTERED)
_____________________________________) 
_____________________________________) 
_____________________________________) NOTICE OF APPEAL 
_____________________________________) 
_____________________________________) 
_____________________________________) 

NOTICE IS GIVEN that (YOUR NAME) hereby Appeals from the 

(Judgment/Decree/Decision, etc.) entered herein on (DATE JUDGMENT 

WAS SIGNED) by the Honorable (NAME OF JUDGE OR JUDICIAL OFFICIAL 

WHO SIGNED JUDGMENT) in the above-captioned action. 

Dated:(DATE)_______________________

_____________________________ 
(YOUR NAME)
(YOUR STREET ADDRESS) 
(YOUR CITY/STATE/ZIP) 
(YOUR PHONE NUMBER) 
Appellant, In Propria Persona 

Original filed with the 
Clerk of this Court, along 
with any fees required by the clerk, 
and copies mailed/delivered on 
this date (DATE OF FILING/MAILING) to: 

(NAME AND ADDRESS OF OTHER PARTY OR ATTORNEY FOR OTHER PARTY) 
(NAME AND ADDRESS OF JUDGE WHO SIGNED THE JUDGMENT APPEALED FROM) 
(OTHER PARTIES WHO RECEIVED COPIES IN THIS CASE)

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