File Stamp UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT Rev. 2/11 CIVIL APPEAL STATEMENT Please TYPE. Attach additional pages if necessary. 11th Circuit Docket Number: _________________________________ Caption: District and Division: Name of Judge: Nature of Suit: Date Complaint Filed: District Court Docket Number: Date Notice of Appeal Filed:  Cross Appeal  Class Action Has this matter previously been before this court?  Yes  No If Yes, provide (a) Caption: (b) Citation: (c) Docket Number: Attorney Name Mailing Address Telephone, Fax, and Email For Appellant:  Plaintiff  Defendant  Other (Specify) For Appellee:  Plaintiff  Defendant  Other (Specify) Please CIRCLE/CHECK/COMPLETE the items below and on page 2 that apply. Jurisdiction Federal Question Nature of Judgment Final Judgment, 28 USC 1291 US Defendant Dismissal/Jurisdiction Relief Amount Sought by Plaintiff: $_______________________ Default Judgment Diversity US Plaintiff Type of Order Interlocutory Order, 28 USC 1292(a)(1) Interlocutory Order Certified, 28 USC 1292(b) Summary Judgment Judgment/Bench Trial Judgment/Jury Verdict Interlocutory Order, Qualified Immunity Judgment/Directed Verdict/NOV Final Agency Action (Review) Injunction 54(b) Amount Sought by Defendant: $_______________________ Awarded: $_______________________ to ______________________ Other ________________________ Injunctions:  TRO  Preliminary  Permanent   Granted Denied American LegalNet, Inc. www.FormsWorkFlow.com Page 2 11th Circuit Docket Number: ____________________________ Based on your present knowledge:  Yes  No (1) Does this appeal involve a question of First Impression? What is the issue you claim is one of First Impression? (2) Will the determination of this appeal turn on the interpretation or application of a particular case or statute?  Yes  No If Yes, provide (a) Case Name/Statute (b) Citation (c) Docket Number if unreported (3) Is there any case now pending or about to be brought before this court or any other court or administrative agency that (a) Arises from substantially the same case or controversy as this appeal?  Yes  No (b) Involves an issue that is substantially the same, similar, or related to an issue in this appeal?  Yes  No If Yes, provide (a) Case Name (b) Citation (c) Docket Number if unreported (d) Court or Agency (4) Will this appeal involve a conflict of law (a) Within the Eleventh Circuit?  Yes (b) Among circuits?  Yes  No  No If Yes, explain briefly: (5) Issues proposed to be raised on appeal, including jurisdictional challenges: I CERTIFY THAT I SERVED THIS CIVIL APPEAL STATEMENT ON THE CLERK OF THE U.S. COURT OF APPEALS FOR THE ELEVENTH CIRCUIT AND SERVED A COPY ON EACH PARTY OR THEIR COUNSEL OF RECORD, THIS ____________ DAY OF ___________________________, ____________. _______________________________________________________ NAME OF COUNSEL (Print) _______________________________________________________ SIGNATURE OF COUNSEL Please ATTACH portion of district court, tax court, or agency record described in 11th Cir. R. 33Ͳ1(b): (a) judgments and orders appealed from or sought to be reviewed; (b) any supporting opinion, findings of fact, and conclusions of law filed by the court or the agency, board, commission, or officer; (c) any report and recommendation adopted by an order; (d) findings and conclusions of an administrative law judge when appealing a court order reviewing an agency determination; (e) any agency docket sheet or record index. American LegalNet, Inc. www.FormsWorkFlow.com