MCF No.

40, 41
Notice of Appeal

Original – Court, 1st Copy – Plaintiff, 2nd Copy – Defendant, Other copies as needed
Enter information in block letters in all parts of the Form except when reserved for Court
use, which shall be completed by the Clerk.
For Court Use Only
(Judicial Region)

(Municipality/City/Province)

 METC/MTCC/MTC/MCTC
 RTC

BRANCH
Case No.
Plaintiff/
Petitioner , v.
Defendant/
Respondent

COUNSEL OR PARTY WITHOUT COUNSEL

Nam
e
Firm Name
Address
Email Address
Tel./Cel./Fax Nos.
PTR No. Date/
Roll No. Place of Issue
 Lifetime
IBP No.  Date/Chapter
 Compliance
MCL  Exemption No
E .
Other Compliances
Counsel for
 Plaintiff/
Petitioner
 Defendant/
Respondent
 Other

NOTICE OF APPEAL
UNDER RULES 40 and 41

___________ files this Notice of Appeal for a review, on both

questions of fact and law, of the:
 decision
 order
 resolution

issued by this Court on _________________, which was

received by the appellant on ________________.

 The record on appeal is simultaneously filed with this Notice.

Page 1 of 2
  The appeal docket fees have been paid as evidenced by O.R.
No. _______________ dated _________, attached as an annex.
 Appellant is exempt from the payment of the appeal docket fees
because ___________________________________________.
PROOF OF SERVICE
A copy of this Request was served upon:
Person’s Name Method Place Served Date Served
Branch Sheriff Personal Service
Licensed Courier
Registered Mail
Facsimile or Other
Electronic Means
Attaching Party Personal Service
Licensed Courier
Registered Mail
Facsimile or Other
Electronic Means
Personal Service
Licensed Courier
Registered Mail
Facsimile or Other
Electronic Means
Personal Service
Licensed Courier
Registered Mail
Facsimile or Other
Electronic Means
Proof of such service is attached to this Request as an Annex.

Date Party/Party’s Counsel Name and Signature

ORDER
The Court

1. approves the Notice of Appeal which was seasonably filed. The Branch Clerk is
directed to transmit the records of the case to the appellate court within 15 days
30 days.

 disapproves the Notice of Appeal as:

 it was filed out of time;
 the appeal fee was not paid;
 no proof of payment was submitted; or
 the appeal fee was paid late.

2.  Appellee is directed to file any comment on the Record on Appeal within five
(5) days from receipt thereof.

Judge Date

SPECIAL INSTRUCTIONS

MOTION FOR EXTENSION OF TIME IS PROHIBITED

No motion for extension of time to file a notice of appeal or pay the appeal fees shall be granted.
[Rule 41.3(2)]

NOTICE OF APPEAL UNDER RULES 54 and 55 page 2 of 2