Court of Common Pleas of Carbon County For Prothonotary Use only (Docket Number) Civil Cover Sheet A. PLAINTIFF’S NAME: DEFENDANT’S NAME: PLANTIFF’S ADDRESS & TELEPHONE NUMBER: DEFENDANT’S ADDRESS AND TELEPHONE NUMBER: PLAINTIFF’S NAME: DEFENDANT’S NAME: PLANTIFF’S ADDRESS & TELEPHONE NUMBER: DEFENDANT’S ADDRESS & TELEPHONE NUMBER: TOTAL NUMBER OF PLAINTIFFS TOTAL NUMBER OF DEFENDANTS B. AMOUNT IN CONTROVERSY C. COMMENCEMENT OF ACTION D. CASE PROCESS ___ $50,000 or less ___ More than $50,000 ___ ___ ___ ___ ___ ___ ___ ___ E. TRACK ASSIGNMENT REQUESTED (CHECK ONE) _____ F. FAST _____ STANDARD _____ COMPLEX 1. 2. 3. 4. Complaint Writ of Summons Notice of Appeal Petition Action 5. Arbitration 6. Jury 7. Non Jury 8. Class Action COURT HAS FINAL APPROVAL FOR ALL TRACK ASSIGNMENTS If complex, state reasons: CODE AND CASE TYPE (See instructions) G. CODE AND CASE SPECIFIC (See instructions) H. STATUTORY BASIS FOR CAUSE OF ACTION (See instructions) I. RELATED PENDING CASES (List by Docket Number – Indicate whether the related cases have been consolidated) J. TO THE PROTHONOTARY: Kindly enter my appearance on behalf of Plaintiff/Petitioner/Appellant. Papers may be served at the address set forth below. NAME OF PLAINTIFF’S/APPELLANT’S ATTORNEY ADDRESS PHONE NUMBER E-MAIL ADDRESS: SUPREME COURT IDENTIFICATION NUMBER _______________________________________________________________ __ FAX NO. (OPTIONAL – FOR SERVICE): DATE: _____________________________ SIGNATURE: _____________________________________________________ Form A Effective July 26, 2004, Revision September 15, 2006 American LegalNet, Inc. www.FormsWorkflow.com Form A Effective July 26, 2004, Revision September 15, 2006 American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Civil Cover Sheet The attorney (or pro se party) filing a case shall complete the form as follows: A. Parties i. ii. iii. Plaintiff(s)/Defendant(s) Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency or corporation, use the full name of the agency or corporation. In the event there are more than two plaintiffs and/or two defendants, list the additional parties on a separate sheet of paper. Husband and wife should be listed as separate parties. Parties' Addresses and Telephone Numbers Enter the address and telephone numbers of the parties at the time of filing of the action. If any party is a corporation, enter the address and telephone number of the registered office of the corporation. Number of Plaintiffs/Defendants Indicate the total number of plaintiffs and the total number of defendants in the action. B. Amount in Controversy Check the appropriate box. Indicate whether an Assessment of Damages Hearing is required. C. Commencement of Action Indicate type of document to be filed to initiate the action. D. Other Indicate whether the case is an arbitration, jury or non-jury case. Check any other appropriate boxes. If the action will require the entry of an Order approving a minor/incapacitated person's compromise, wrongful death or survival action, check the appropriate box. E. Track Assignment – COURT HAS FINAL APPROVAL FOR ALL TRACK ASSIGNMENTS If you are requesting the Complex track, please indicate the reasons for your request. F. Type of Action - Case Type Select and insert the applicable case type and code from the first two columns of the following list: Code @ X A = C 1 D B W N 2 L Case Type Asbestos Case Assessment Appeal Civil Action Consumer ProtectionAssurance Voluntary Compliance Custody Declaratory Judgment Divorce DJ Appeal Ejectment Eminent Dom./Dec. of Tak. EminentDomain/Pet.Viewer s License Appeal Code Case Type Code Case Specific Code 9 # F $ Mandamus Miscellaneous Mortgage Foreclosure Municipal Appeal 001 018 015 019 Assault/Battery Class Action Consumer Credit Contract – Construction 005 009 032 002 M V Prop Damage Negotiable Instrument Partition Premises Liability 7 Q R ! V Name Change Quiet Title Replevin Tax Sale Zoning Appeal 011 012 025 035 030 043 016 040 Contract - Sale of Goods Contract – Other Defamation Discrimination Employment/Wrongful Disc. Equity Fraud Indirect Criminal Contempt 003 027 022 006 010 013 039 024 Personal Injury Product Liability Prof.Malprac.Liability Actn Property Damage (non-veh) Recov. Overpaymt. Rent/Lease/Ejectment Right to Know Stockholder Suit 008 034 033 042 007 037 Insurance-Declar. Judgment Malicious Prosecution Mechanic’s Lien Medical Prof. Liability Action Motor Veh. Accdt.>$25,000 Motor.Veh. Accdt.