UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA DESIGNATION FORM (to be used by counsel or pro se plaintiff to indicate the category of the case for the purpose of assignment to the appropriate calendar) Address of Plaintiff: Address of Defendant: Place of Accident, Incident or Transaction: RELATED CASE, IF ANY: Case Number: Judge: Date Terminated: Civil cases are deemed related when Yes is answered to any of the following questions: 1.Is this case related to property included in an earlier numbered suit pending or within one yearYes No previously terminated action in this court? 2.Does this case involve the same issue of fact or grow out of the same transaction as a prior suitYes No pending or within one year previously terminated action in this court?3.Does this case involve the validity or infringement of a patent already in suit or any earlierYes No numbered case pending or within one year previously terminated action of this court?4.Is this case a second or successive habeas corpus, social security appeal, or pro se civil rightsYes No case filed by the same individual? I certify that, to my knowledge, the within case is / is not related to any case now pending or within one year previously terminated action in this court except as noted above. DATE: Attorney-at-Law / Pro Se Plaintiff Attorney I.D. # (if applicable) CIVIL: A. Federal Question Cases: 1. Indemnity Contract, Marine Contract, and All Other Contracts2. FELA3. Jones Act-Personal Injury4. Antitrust5. Patent6. Labor-Management Relations7. Civil Rights8. Habeas Corpus9. Securities Act(s) Cases10. Social Security Review Cases11. All other Federal Question Cases(Please specify): B. Diversity Jurisdiction Cases: 1. Insurance Contract and Other Contracts2. Airplane Personal Injury3. Assault, Defamation4. Marine Personal Injury5. Motor Vehicle Personal Injury6. Other Personal Injury (Please specify): 7. Products Liability8. Products Liability 226 Asbestos9. All other Diversity Cases(Please specify): ARBITRATION CERTIFICATION ( I, , counsel of record or pro se plaintiff, do hereby certify: Pursuant to Local Civil Rule 53.2, 247 3(c) (2), that to the best of my knowledge and belief, the damages recoverable in this civil action caseexceed the sum of $150,000.00 exclusive of interest and costs: Relief other than monetary damages is sought. DATE: Attorney-at-Law / Pro Se Plaintiff Attorney I.D. # (if applicable) NOTE: A trial de novo will be a trial by jury only if there has been compliance with F.R.C.P. 38. Civ. 609 (/2018) American LegalNet, Inc. www.FormsWorkFlow.com