OHIO FIFTH DISTRICT COURT OF APPEALS DOCKETING STATEMENT WARNING: A time-stamped copy of the judgment entry or order which makes your cause appealable as well as a copy of all judgment entries or orders being appealed must be attached to this statement. All requested information must be provided. Failure to file a fully completed docketing statement, typed or legibly printed, may result in this appeal being dismissed by the Court, sua sponte. Appeal No._________________________________________ Trial Court No. _____________________________________ _____________________________________ Plaintiff-Appellant Appellee (Circle Designation) -vs________________________________________ Trial Court Judge____________________________________ WARNING: _______________________________________ Plaintiff's Counsel___________________________________ Phone_____________________________________________ Defendant's Counsel_________________________________ _________________________________________ Defendant-Appellant Appellee (Circle Designation) A. DATES: Of the judgment(s) being appealed ________ Phone_____________________________________________ Time to Appeal extended per App.R. ( )Yes ( )No Specify Reason: __________________________ B. PROBABLE ISSUES FOR REVIEW: (Including charges in criminal case)____________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ C. THIS APPEAL SHOULD BE ASSIGNED TO: (Check One) (See Loc. App. R. 6(B) and App. R. 11.2) () () () The regular calendar, The accelerated calendar, (See Loc. R. 6(B)) The expedited calendar. (See Section F(3) of this docketing statement, Loc. R. 7 and App. R. 11.2) This Docketing Statement will serve as a praecipe to the clerk to prepare and transfer the docket and journal entries. Please Indicate the Type of Record to be Filed: (Check One). ( ( ) ) Docket and Journal Entries Only, no transcript of proceedings. Transcript has been prepared already. It is a ( ) Full or ( ) Partial Transcript. If partial, see App.R. 9(B) Statement of the record pursuant to App.R. 9(C). Agreed Statement of the Record pursuant to App.R. 9(D). Transcript of Proceedings. ( ) Less than or ( ) Greater than 100 pages. ( ) Full or ( ) Partial transcript has been ordered. If partial, see App.R. 9(B). WARNING: If a transcript of proceedings is needed, a copy of the notice of appeal and an appropriate praecipe must be served by Appellant on the court reporter. A copy of the praecipe to the court reporter shall be filed with this Court showing service of the notice of appeal and praecipe upon the court reporter. D. THE RECORD: () () ( ) NAME OF COURT REPORTER, DATE SERVED __________________________________________________ Please state with particularity which exhibits and/or evidence, other than paper exhibits or documentary evidence not of unusual bulk or weight, the parties request be transmitted as part of the record on appeal. (See APP.R. 10(B); Loc.App.R. 8(C))________________________________________________________________________________________ 17 American LegalNet, Inc. www.FormsWorkFlow.com E. CRIMINAL CASE 1. CHARGE: ________________________________________________________________________________________________ 2. DEGREE: ( ) Misdemeanor ( ) Felony 3. Is this an appeal of probation revocation? ( ) Yes ( ) No. If yes, what was the original charge and sentence? ____________________________________________________________________________________________________________ 4. Is this an appeal of Post-Conviction Relief? (R.C. 2953.21) ( ) Yes ( ) No. If yes, was a hearing held in the trial court? ( ) Yes ( ) No. What was the original charge and sentence? _______________________________________________________ 5. Type of Appeal: (Check One) () Appeal as of Right ( ) State's Appeal as of Right (R.C. 2945.67(A)) () Appeal by Leave of Court (App.R. 5) ( ) State's Appeal by Leave of Court 6. Is this an appeal for review of sentencing pursuant to R.C. 2953.08? ( ) Yes ( ) No. 7. Was counsel appointed for trial? ( ) Yes ( ) No. 8. Was counsel appointed for appeal? ( ) Yes ( ) No. 9. Was a stay of sentence requested in trial court? ( ) Yes ( ) No If yes, stay was: GRANTED DENIED PENDING F. CIVIL CASE 1.ACTION BROUGHT IN LOWER COURT:______________________________________________________________________ ___________________________________________________________________________________________________________ 2. Did this action originate in a Trial Court or in an Administrative Agency? Indicate which. ( ( ) County Court ) Probate Court ( ( ) Municipal Court ( ) Family Court ( ) Common Pleas Court ( ) Juvenile Court ( ) Administrative Agency ) Other _____________ )Yes ( )No. If yes, check one of the following: 3. Must this case be expedited as being one of the following types: ( ( ( ( ) Appeal under determination of local fiscal emergency brought by municipal corporation R.C. 118.04(C) ) Appeal brought by minor child under R.C. 2505.073 ) Appeal involving matters of child custody, allocation of parental rights or responsibilities, or designation of a child's place of residence and legal custodian under R.C. 3109.04(H) and R.C. 3109.06. ( ) Appeal from orders granting or denying (1) termination of parental rights or (2) adoption of a minor child.(See App. R. 11.2 effective July I, 2000) See Loc. R. 7 ( ) Appeal from orders regarding dependent, abused, neglected, unruly, or delinquent children. (See App. R. 11.2 effective July I, 2000) See Loc. R. 7 ( ) Election contests as provided in R.C. 3515.08 ) Yes ( ) No. If yes, please cite case(s). 4. Do you know of another case pending in this Court which raises the same issue(s)? ( ____________________________________________________________________________________________________________ 5. Have you determined in good faith that the judgment appealed from is a final appealable order? (R.C. 2505.02) ( ) Yes ( ) No. ( ) Yes ( ) No. ( ) Yes ( ) No. 6. Did the judgment dispose of all claims by and against all parties? 7. If not, is there an express determination that there is "no just reason for delay"? (Civ.R. 54(B)) 8. Was a stay of judgment requested in trial court? ( ) Yes ( ) No If yes, stay was: GRANTED DENIED PENDING CERTIFICATION I certify that the information provided on this docketing statement is accurate. _______________________________________________