Rev. 4/18 UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT 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 H as this matter previously been before this court? Yes No If Yes, provide (a) Caption: (b) Citation: (c ) Docket Number : Attorney Name 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. Mailing Address Telephone, Fax, Email Jurisdiction Nature of Judgment Type of Order Relief Federal Question Diversity US Plaintiff US Defendant Final Judgment, 28 USC 1291 Interlocutory Order, 28 USC 1292(a)(1) Interlocutory Order Certified, 28 USC 1292(b) Interlocutory Order, Qualified Immunity Final Agency Action (Review) 54(b) Dismissal/Jurisdiction Default Judgment Summary Judgment Judgment/Bench Trial Judgment/Jury Verdict Judgment/Directed Verdict/NOV Injunction Other Amount Sought by Plaintiff: $ Amount Sought by Defendant: $ Awarded: $ to Injunctions: TRO Preliminary Granted Permanent Denied American LegalNet, Inc. www.FormsWorkFlow.com Page 2 11th Circuit Docket Number: Based on your present knowledge: (1) Does this appeal involve a question of First Impression? Yes No 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 No (b) Among circuits? Yes 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 American LegalNet, Inc. www.FormsWorkFlow.com