UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT PRO SE DOCKETING STATEMENT INSTRUCTIONS: Appellant must complete the entire docketing statement form and attach copies of the following documents: (1) the notice of appeal; (2) the order or judgment being appealed; and (3) any written findings, conclusions or order of the trial court relating to the order of judgment being appealed. The completed docketing statement, together with the attachments, must be filed with the clerk of the court of appeals within 10 days after filing the notice of appeal. A copy of the completed docketing statement, with attachments, must be served on all opposing parties or their counsel. Proof of service must be provided. You must complete the certificate of service which is part of this form. 1. Your name, address, including registration number if applicable:______________ ________________________________________________________________________ ________________________________________________________________________ 2. Title and number of district court case:__________________________________ ______________________________________________________________________ 3. Name of the district court:___________________________________________ 4. The dates on which the district court order and your notice of appeal were filed: _________________________________________________________________ 5. Type of action: ____________ habeas corpus ____________ § 2255 motion ____________ motion to reduce sentence ____________ civil action for damages ____________ other [specify] _______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 6. State briefly the relief you requested in the district court and the reasons why you are entitled to such relief:_____________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 7. State briefly the reasons why you feel the decision of the district court should be reversed:___________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 8. Did you have a hearing in the district court? ______________________________ _________________________________________ Signature D-3 Pro Se Docketing Statement 06/09 _______________________ Date Page 2 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I, _______________________________________ hereby certify that on [appellant/petitioner] ____________________ I served a copy of the foregoing Pro Se Docketing Statement, [date] to: _____________________________________, at ___________________________ [appellee/respondent or attorney therefor] ___________________________________________________________________ ________________________________________________, the last known address/email address by _____________________________. [state method of service] _____________________________________________ Signature _____________________________________________ Dated signed _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ [Full name and address of person completing service] D-3 Pro Se Docketing Statement 06/09 Page 3 American LegalNet, Inc. www.FormsWorkFlow.com