APPENDIX E: LOUISIANA COURT OF APPEAL, SECOND CIRCUIT WRIT APPLICATION INTAKE FORM TO BE COMPLETED BY PARTY FILING APPLICATION Approved by Administrative Court Conference April 3, 2014 TYPE OF PLEADING: _____Civil Expedited Consideration Requested? _____Criminal _____Yes _____Other (explain) _______________________________________ _____No Stay Order Requested? _____Yes _____No If yes, on what basis? _________________________________________________________________________________________ Pleading being filed ______ By Attorney ______ In Proper Person/Pro Se _______ In Forma Pauperis (pauper order must be attached) LOWER COURT INFORMATION CASE TITLE: ______________________________________________________________________________________________ Versus ___________________________________________________________________________________________________________ Parish and Judicial District: ______________________________________________ Docket No(s):___________________________ Trial/Ruling Judge: ____________________________________________________ Ruling Date: ____________________________ What was the ruling of the trial court? _____________________________________________________________________________ PRESENT CASE STATUS (please check all that apply) _____Pretrial _____Bench trial _____Post-trial/hearing _____Jury trial _____Hearing or trial date and time: _____________________ Stay by trial court? ______Denied _____Trial in progress ______Granted until_______________________ Lead counsel for Respondent Lead counsel for Applicant Name: ___________________________________________ Firm Name: _______________________________________ Address: __________________________________________ __________________________________________________ Phone No: ________________ Fax No: _________________ Email: ____________________________________________ Bar Roll No: ________ Name(s) of party/parties represented: __________________________________________________ Name: ____________________________________________ Firm Name: ________________________________________ Address: __________________________________________ __________________________________________________ Phone No: ________________ Fax No: _________________ Email: ____________________________________________ Bar Roll No: ________ Name(s) of party/parties represented: __________________________________________________ Attach a list of any additional counsel/pro se litigants, their addresses/contact information, and the parties they represent. Have there been any previous filings, appeals or writ applications in this Court in this case? ________Yes ________No If yes, explain: _______________________________________________________________________________________________ PENDING CASE INFORMATION Are there any appeals or writ applications related to the present matter currently pending before this Court? ________Yes ________No If yes, provide the appellate court docket number, date of filing and name of filing party: ___________________________________________ ____________________________________________________________________________________________________________ Would any of those pending matters impact the current filing or will the current filing impact any of the pending matters? _______Yes ______No If yes, explain: _______________________________________________________________________________________________ ____________________________________________________________________________________________________________ Has this pleading been filed simultaneously in any other court? _______Yes _______No If yes, explain: _______________________________________________________________________________________________ VERIFICATION I hereby verify that the above information and all of the information contained in this application is true and correct to the best of my knowledge and that all relevant pleadings, rulings, and orders, as required by Uniform Rules 4-2, 4-3 and 4-5 of the Courts of Appeal are attached to this filing. I further certify that a copy of this application has been mailed or delivered to the respondent judge and to opposing counsel, and to any opposing party not represented by counsel. I understand that failure to comply with Uniform Rules 4-2, 4-3 and 4-5 of the Courts of Appeal may result in the refusal to consider or dismissal of my application. Pursuant to URCA Rule 4-5(D), I shall immediately notify the Court if any trial or hearing date is set or changes, or the need for expedited consideration changes due to settlement, continuance, or any other circumstance. FAILURE TO NOTIFY THE COURT MAY SUBJECT ME TO PUNISHMENT FOR CONTEMPT OF COURT. __________________________________________________________________________________________________ DATE PRINT NAME SIGNATURE/BAR ROLL NO. American LegalNet, Inc. www.FormsWorkFlow.com