8 July 2003 Rule 6.751 — Form 1 IN THE SUPREME COURT OF IOWA No. __________ __________ COUNTY NO. ________ } COMBINED CERTIFICATE [See Iowa R. App. P. 6.10(2)] ____________________________________________________________________________________________ 1. Notice of appeal was filed in district court on _________________________, from a judgment or ruling filed on (Date) ________________________________. (Date) 2A. I hereby certify that I ( ______ now order)* ( ______ have ordered) on the _________________________________ day of _______________________, 20 _____, a transcript, or portions thereof, from: (1) _________________________________ ______________________________________________ (Court Reporter Name) (Address) (2) _________________________________ ______________________________________________ No arrangements have been made or suggested to delay the preparation thereof. I will pay for the transcript in accordance with Iowa R. App. P. 6.10(2). The following proceedings ( __________ are)* ( __________ were) ordered: (1) _______________________________________________________________________________________ (Describe parts ordered) before _____________________________________________ on _____________________________________ (Judge) (Date) (2) _______________________________________________________________________________________ before _____________________________________________ on _____________________________________ –OR– 2B. I need not order a transcript under Iowa R. App. P. 6.10(3) because: _________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________. I ( ______ will) ( ______ will not) prepare a statement of the evidence or proceedings pursuant to Iowa R. App. P. 6.10(3). *This certificate may be used as an order form. American LegalNet, Inc. www.FormsWorkflow.com 2C. [To be completed by appellant if less than full transcript is ordered] The issues appellant(s) intends to present on appeal are: I. II. III. 3. If Iowa R. App. P. 6.12(2), 6.17, or 6.105 applies to this case, check category: _____ a contest as to custody of children, an adoption, or a juvenile proceeding affecting child placement; _____ a termination of a parent-child relationship; _____ a conviction and sentence on a plea of guilty or a sentence only; _____ an original certiorari proceeding; _____ a certified question of law; _____ a lawyer disciplinary matter; _____ proceedings which have not been recorded in such a manner that a transcript of those proceedings can be made; _____ judicial review of an administrative action pursuant to Iowa Code chapter 17A, where no additional testimony was introduced in district court. 4. I assert in good faith that this appeal meets jurisdictional requirements and is from: _____ a final judgment, order, or decree and a timely notice of appeal has been filed; –OR– _____ an interlocutory ruling where permission for appeal has been requested and granted by the supreme court. 5. The names of the parties involved in this appeal and their designations in district court are shown below under column A. Their respective attorneys’ names, law firms, addresses, and telephone numbers are shown below under column B: Column A Parties Column B Attorneys Appellant(s): Appellee(s): Appellant’s Name ___________________________________ By _______________________________________________ __________________________________________________ __________________________________________________ (Name, address, and telephone number of attorney or, if none, of appellant.) American LegalNet, Inc. www.FormsWorkflow.com 0 PROOF OF SERVICE AND CERTIFICATE OF FILING I certify that on ____________________________, 20 _____, I served this document by ( _____________ personally delivering) ( _____________ mailing) a copy to all other parties in this matter and to the court reporter(s) from whom the transcript has been ordered at their respective addresses as shown below: I further certify that on ______________________, 20 _____, I will file this document by ( __________ personally delivering) ( __________ mailing) a copy of it to the Clerk of the District Court for ____________________ County. I further certify that on ______________________, 20 _____, I will file this document by ( _________ personally delivering) ( _________ mailing) 3 copies of it to the Clerk of the Supreme Court, Iowa Judicial Branch Building, 1111 East Court Avenue, Des Moines, Iowa 50319. __________________________________________________ SIGNATURE OF PERSON SERVING AND FILING American LegalNet, Inc. www.FormsWorkflow.com