Note to court: This form must be given to the defendant/juvenile at sentencing. A separate form must be provided for each case. Additionally, when this 
request is filed with the court, the court must serve MAACS with a copy of the written order denying or appointing counsel. MCR 6.425(G)(1)(g).

1. You are entitled to appellate review of your conviction and sentence. This is done by filing a
claim of appeal by right, or when you are not entitled to file a claim of appeal by right, an
application for leave to appeal. If you pled guilty or nolo contendere, an appeal must be done by
filing an application for leave to appeal.

Date

Receipt of Notice

2. If you cannot afford to hire an attorney to represent you on appeal and you request an attorney,

an attorney may be appointed for you.

Defendant’s/Juvenile’s initials

3. You may request an attorney by completing the request for appointment of attorney section below and
returning this form to the trial court or the Michigan Assigned Counsel System (MAACS) at the address
listed below. If you were convicted by trial and wish to preserve your automatic right to appeal, the form
must be received within 42 days after sentencing. If you were convicted by plea or do not submit this form
within 42 days after sentencing, you may still file an application for leave to appeal if the form is received
within 6 months after sentencing.

REQUEST FOR APPOINTMENT OF ATTORNEY
Instructions to defendant/juvenile: To request an attorney to represent you on appeal, the completed and signed form should be received 
by the trial court or MAACS within the timeline outlined above. Keep a copy for yourself. To submit the form to MAACS, please send the 
form to: Michigan Appellate Assigned Counsel System, 200 N. Washington Square, Suite 250, Lansing, MI 48913.

I request appointment of an attorney to represent me on appeal. I provide the following financial information for the court to 
determine whether I am indigent.
► 

◄

Date
Residence

 

 Rent 
 
 Live with relative(s)     

 Own 

 

 

 Room/Board
Prison 

Number

Employer name and address

Signature of defendant/juvenile

Marital Status

 Single 
Dependents: 

Number

Length of employment

 Married 

 Divorced 

 Separated

Other income  State monthly amount and source. E.g., MDHHS, VA, rent, pensions, spouse, unemployment. 

Average pay 

 weekly 

 every two weeks

Gross: $ 

 monthly 

     Net: $ 

Assets  State value of car, home, bank accounts, inmate accounts (attach a certified account statement), etc.

Obligations/Debts 

Itemize monthly rent, installment payments, mortgage payments, child support, etc.

 NONE

 NONE

 NONE

 NONE

CC 265 (12/21) NOTICE OF RIGHT TO APPELLATE REVIEW AND REQUEST FOR APPOINTMENT OF ATTORNEYMCR 6.425(F), (G), (H)THE PEOPLE OF THE STATE OF MICHIGANvDefendant’s/Juvenile’s name, address, and telephone no.Approved, SCAOOriginal - Trial court1st copy - Prosecutor2nd copy - Defendant/Juvenile for return3rd copy - Defendant/JuvenileSTATE OF MICHIGANJUDICIAL CIRCUITCOUNTY NOTICE OF RIGHT TO APPELLATE REVIEWAND REQUEST FORAPPOINTMENT OF ATTORNEYCASE NO.Judge:Court addressCourt telephone no.