CIV117 State ENG Rev 05/13www.mncourts.gov/formsPage 1 of 4State of Minnesota District Court County of Select County Judicial District: Court File Number: Case Type: Defendant (first, middle, last) Plaintiff (first, middle, last)vs. Date Case Filed:Civil Cover Sheet (Non-Family Case Type) Minn. R. Gen. Prac. 104This civil cover sheet must be filed by the initial filing lawyer or party, if unrepresented by legal counsel, unless the court orders all parties or their legal counsel to complete this form. Once the initial civil cover sheet is filed, opposing lawyers or unrepresented parties who have not already been ordered to complete this form may submit their own cover sheet within ten days after being served with the initial cover sheet. See Rule 104 of the General Rules of Practice for the District Courts. If information is not known to the filing party at the time of filing, it shall be provided to the Court Administrator in writing by the filing party within seven (7) days of learning the information. Any party impleading additional parties shall provide the same information to the Court Administrator. The Court Administrator shall, upon receipt of the completed certificate, notify all parties or their lawyers, if represented by counsel, of the date of filing the action and the file number assigned. ATTORNEY FOR PLAINTIFF Attorney Name (not firm name) Postal Address City State Zip Code Telephone Number E-mail Address Minnesota Attorney ID NumberATTORNEY FOR DEFENDANT Attorney Name (not firm name) Postal Address City State Zip Code Telephone Number E-mail Address Minnesota Attorney ID Number American LegalNet, Inc. www.FormsWorkFlow.com CIV117 State ENG Rev 05/13www.mncourts.gov/formsPage 2 of 4PLAINTIFF, Self-represented Name Postal Address City State Zip Code Telephone Number E-mail AddressDEFENDANT, Self-represented Name Postal Address City State Zip Code Telephone Number E-mail Address(Attach additional sheets for additional attorneys / parties) Note: If either Plaintiff or Defendant gets an attorney, the attorney's name, address, telephone number and attorney ID number must be given in writing to the Court Administrator immediately. 1. Provide a concise statement of the case including facts and legal basis: 2. Date Complaint was served: 3. For Expedited Litigation Track (ETLT) Pilot Courts only:a. The parties jointly and voluntarily agree that this case shall be governed by the Special Rules of ELT Pilot. Date of agreement: b. The court is requested to consider excluding this case from ELT for the following reasons: Note: ELT is mandatory in certain cases, and where mandatory, exclusion may also be sought by timely motion under the Special Rules for ELT Pilot.c. Anticipated number of trial witnesses: d. Amount of medical expenses to date: e. Amount of lost wages to date: f. Identify any known subrogation interests: 4. Estimated discovery completion within months from the date of this form. American LegalNet, Inc. www.FormsWorkFlow.com CIV117 State ENG Rev 05/13www.mncourts.gov/formsPage 3 of 45. Disclosure/discovery of electronically stored information discussed with other party? No YesDate of discussion: If yes, list agreements, plans and disputes: 6. Proposed trial start date: 7. Estimated trial time: dayshours (estimates less than a day must bestated in hours).8. Jury trial is: waived by consent of requested by (specify party)pursuant to Minn. R. Civ. P. 38.02. (specify party)(NOTE: Applicable fee must be enclosed)9. Physical/mental/blood examination pursuant to Minn. R. Civ. P. 35 is requested. Yes No10. Identify any party or witness who will require interpreter services, and describe the services needed (specifying language, and if known, particular dialect): 11. Issues in dispute: 12. Case Type/Category: (NOTE: select case types from Form 23,Subject Matter Index for Civil Cases, appended to the Minnesota Rules of Civil Procedure).13. Recommended Alternative Dispute Resolution (ADR) mechanism: (See list of ADR processes set forth in Minn. Gen. R. Prac. 114.02(a))Recommended ADR provider (known as a "neutral") Recommended ADR completion date: If applicable, reasons why ADR not appropriate for this case: By signing below, the attorney or party submitting this form certifies that the above information is true and correct.Submitted by: American LegalNet, Inc. www.FormsWorkFlow.com CIV117 State ENG Rev 05/13www.mncourts.gov/formsPage 4 of 4 Signature Name: Attorney Reg. #: Firm/Agency Name: Street Address: City/State/Zip Code: Telephone: Date: American LegalNet, Inc. www.FormsWorkFlow.com