Supreme Court of the State of New York
Appellate Division: Judicial Department

Informational Statement (Pursuant to 22 NYCRR 1250.3[a]) — Civil

Case Title:

Set forth the title of the case as it appears on the summons, notice of petition or order to show cause by which the matter was or is to be commenced, or as amended.

Appellant

- against -

Respondent

For Court of Original Instance

Date Notice of Appeal Filed

For Appellate Division

Case Type

Civil Action

CPLR Article 75 Arbitration

Action Commenced under CPLR 214-g

Action Commenced under CPLR 214-j

CPLR Article 78 Proceeding

Special Proceeding Other

Habeas Corpus Proceeding

Filing Type

Appeal

Original Proceedings

CPLR Article 78

Eminent Domain

Labor Law 220 or 220-b

Public Officers Law § 36

Real Property Tax Law § 1278

Transferred Proceeding

CPLR Article 78 (Transferred)

Executive Law § 298

CPLR 5704 Review

Nature of Suit: Check up to three of the following categories which best reflect the nature of the case.

Administrative Review

Business Relationships

Commercial

Contracts

Declaratory Judgment

Domestic Relations

Election Law

Estate Matters

Family Court

Mortgage Foreclosure

Miscellaneous

Prisoner Discipline & Parole

Real Property (other than foreclosure)

Statutory

Taxation

Torts

Informational Statement – Civil | Page 1

Appeal

If an appeal has been taken from more than one order or judgment by the filing of this notice of appeal, please indicate the below information for each such order or judgment appealed from on a separate sheet of paper.

Paper Appealed From (Check one only)

Amended Decree

Amended Judgment

Amended Order

Decision

Decree

Determination

Finding

Interlocutory Decree

Interlocutory Judgment

Judgment

Order

Order & Judgment

Partial Decree

Resettled Decree

Resettled Judgment

Resettled Order

Ruling

Other (specify):

Court

County

Dated

Entered

Judge (name in full)

Index No.

Stage:

Interlocutory

Final

Post-Final

Trial:

Yes

If Yes, Trial Type:

Jury

Non-Jury

Prior Unperfected Appeal and Related Case Information

Are any appeals arising in the same action or proceeding currently pending in the court?

Yes

If Yes, please set forth the Appellate Division Case Number assigned to each such appeal.

Where appropriate, indicate whether there is any related action or proceeding now in any court of this or any other jurisdiction, and if so, the status of the case:

Original Proceeding

Commenced by:

Order to Show Cause

Notice of Petition

Writ of Habeas Corpus

Date Filed

Statute authorizing commencement of proceeding in the Appellate Division

Proceeding Transferred Pursuant to CPLR 7804(g)

Court

County

Judge (name in full)

Order of Transfer Date

CPLR 5704 Review of Ex Parte Order

Court

County

Judge (name in full)

Dated

Description of Appeal, Proceeding or Application and Statement of Issues

Description: If an appeal, briefly describe the paper appealed from. If the appeal is from an order, specify the relief requested and whether the motion was granted or denied. If an original proceeding commenced in this court or transferred pursuant to CPLR 7804(g), briefly describe the object of proceeding. If an application under CPLR 5704, briefly describe the nature of the ex parte order to be reviewed.

Informational Statement – Civil | Page 2

Issues: Specify the issues proposed to be raised on the appeal, proceeding, or application for CPLR 5704 review, the grounds for reversal or modification to be advanced, and the specific relief sought on appeal.

Issues

Party Information

Instructions: Fill in the name of each party to the action or proceeding, one name per line. If this form is to be filed for an appeal, indicate the status of the party in the court of original instance and his, her, or its status in this court, if any. If this form is to be filed for a proceeding commenced in this court, fill in only the party's name and his, her, or its status in this court.

No.	Party Name	Original Status	Appellate Division Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Informational Statement – Civil | Page 3

Attorney Information

Instructions: Fill in the names of the attorneys or firms for the respective parties. If this form is to be filed with the notice of petition or order to show cause by which a special proceeding is to be commenced in the Appellate Division, only the name of the attorney for the petitioner need be provided. In the event that a litigant represents herself or himself, the box marked “Pro Se” must be checked and the appropriate information for that litigant must be supplied in the spaces provided.

Attorney/Firm Name

Address

City

State

Zip

Telephone No.

E-mail

Attorney Type:

Retained

Assigned

Government

Pro Se

Pro Hac Vice

Party or Parties Represented (set forth party number(s) from table above):

Attorney/Firm Name

Address

City

State

Zip

Telephone No.

E-mail

Attorney Type:

Retained

Assigned

Government

Pro Se

Pro Hac Vice

Party or Parties Represented (set forth party number(s) from table above):

Attorney/Firm Name

Address

City

State

Zip

Telephone No.

E-mail

Attorney Type:

Retained

Assigned

Government

Pro Se

Pro Hac Vice

Party or Parties Represented (set forth party number(s) from table above):

Attorney/Firm Name

Address

City

State

Zip

Telephone No.

E-mail

Attorney Type:

Retained

Assigned

Government

Pro Se

Pro Hac Vice

Party or Parties Represented (set forth party number(s) from table above):

Attorney/Firm Name

Address

City

State

Zip

Telephone No.

E-mail

Attorney Type:

Retained

Assigned

Government

Pro Se

Pro Hac Vice

Party or Parties Represented (set forth party number(s) from table above):

Attorney/Firm Name

Address

City

State

Zip

Telephone No.

E-mail

Attorney Type:

Retained

Assigned

Government

Pro Se

Pro Hac Vice

Party or Parties Represented (set forth party number(s) from table above):

Informational Statement – Civil | Page 4