STARK COUNTY COMMON PLEAS COURT CIVIL DESIGNATION FORM PURSUANT TO LOCAL RULE 9.02, THIS FORM MUST BE FILLED OUT IN ITS ENTIRETY. IF THIS FORM IS NOT FILLED OUT IN ITS ENTIRETY, THE COMPLAINT AND ALL OTHER DOCUMENTS WILL BE RETURNED BY THE CLERK WITHOUT FILING. CASE NUMBER ____________________________ PLAINTIFF -vs- DEFENDANT Has this case been previously filed and dismissed? ____Yes ____No. If yes, list case no. and judge.______________________________________________________________________ List all related pending case(s) including case number and judge. _______________________ CIVIL CATEGORIES: PLACE (X) IN ONE CATEGORY ONLY { } A. Professional Tort { } Medical Malpractice { } Dental Malpractice { } Optometric Malpractice { }Chiropractic Malpractice { } Legal Malpractice { } Other Malpractice { } B. Product Liability { } C. Other Tort { } Personal Injury { } Personal Injury- Auto { } Miscellaneous { } D. Workers Compensation Brief Factual Summary: { } H. Other Civil { } Contract Case { } Miscellaneous Civil { } Real Property { } Consumer Sales Practices Act { } Credit Card Case { } E. Foreclosure { } F. Administrative Appeal { } G. Complex Litigation Classification Requested Description of damages including all special damages to date: Do you think this case should be referred to the Court Mediation Program at this time? __Yes__No Reasons: Is this case based on a violation of the Ohio Mortgage Broker Act (ORC 1322) ? ____ Yes _____No _________________________________ Firm Name (Print or Type) _________________________________ Address _________________________________ Telephone REV. 9/09 ________________________________________ Attorney of Record (Print or Type) ________________________________________ Signature _________________________________________ Attorney Registration Number American LegalNet, Inc. www.FormsWorkFlow.com