Court of Common Pleas of Philadelphia County Trial Division For Prothonotary Use Only (Docket Number) Civil Cover Sheet PLAINTIFF'S NAME DEFENDANT'S NAME PLAINTIFF'S ADDRESS DEFENDANT'S ADDRESS PLAINTIFF'S NAME DEFENDANT'S NAME PLAINTIFF'S ADDRESS DEFENDANT'S ADDRESS PLAINTIFF'S NAME DEFENDANT'S NAME PLAINTIFF'S ADDRESS DEFENDANT'S ADDRESS TOTAL NO. OF DEFENDANTS TOTAL NUMBER OF PLAINTIFFS COMMENCEMENT OF ACTION Complaint Writ of Summons AMOUNT IN CONTROVERSY Petition Action Notice of Appeal Transfer From Other Jurisdictions COURT PROGRAMS $50,000.00 or less More than $50,000.00 Arbitration Jury Non-Jury Other: Mass Tort Savings Action Petition Minor Court Appeal Statutory Appeals Commerce (Completion of Addendum Required) Settlement Minors W/D/Survival CASE TYPE AND CODE (SEE INSTRUCTIONS) STATUTORY BASIS FOR CAUSE OF ACTION (SEE INSTRUCTIONS) RELATED PENDING CASES (LIST BY CASE CAPTION AND DOCKET NUMBER) IS CASE SUBJECT TO COORDINATION ORDER? Yes No 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/PETITIONER'S/APPELLANT'S ATTORNEY PHONE NUMBER ADDRESS (SEE INSTRUCTIONS) FAX NUMBER SUPREME COURT IDENTIFICATION NO. E-MAIL ADDRESS SIGNATURE DATE 01-101 (Rev. 6/08) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Civil Cover Sheet Rules of Court require that a Civil Cover Sheet be attached to any document commencing an action (whether the action is commenced by Complaint, Writ of Summons, Notice A. Parties i. Plaintiffs/Defendants Supplemental Parties Form. Husband and wife are to be listed as separate parties. ii. Parties' Addresses iii. Number of Plaintiffs/Defendants: B. Commencement Type: C. Amount in Controversy: Check the appropriate box. D. Court Program: Check the appropriate box. E. Case Types: by rules of court. Proceedings Commenced by Appeal Actions Commenced by Writ of Summons or Complaint Minor Court 5M Money Judgment 5L Landlord and Tenant 5D Denial Open Default Judgment 5E Code Enforcement Other: Local Agency 5B Motor Vehicle Suspension Breathalizer 5V Motor Vehicle Licenses, Contract 5C 5K 5Q 5R 5X 5Z 52 Civil Service Philadelphia Parking Authority Liquor Control Board Board of Revision of Taxes Tax Assessment Boards Zoning Board Board of View Other: Proceedings Commenced by Petition 8P Appointment of Arbitrators 8C Name Change - Adult 8L Compel Medical Examination 8D Eminent Domain 8E Election Matters 8F Forfeiture Tort 2B 2L 4F Professional Malpractice 2D Dental 4L Legal 2M Medical 4Y Other: Assault and Battery Libel and Slander Fraud Equity E2 Wrongful Use of Civil Process Other: Negligence 2V Motor Vehicle Accident Real Estate 2E Real Property 3D 4M Motor Vehicle Property Damage 3F 2S 2P 2T 3E Premises Liability - Slip & Fall Product Liability Toxic Tort T1 Asbestos TZ DES T2 Implant Toxic Waste Other: Mortgage Foreclosure - Residential Owner Occupied Mortgage Foreclosure - Not Residential Not Owner Occupied Prevent Waste Other: 8M Mental Health Proceedings 8G Civil Tax Case - Petition Other: F. Commerce Program G. Statutory Basis for Cause of Action H. Related Pending Cases I. Plaintiff's Attorney The current version of the Civil Cover Sheet may be downloaded from the FJD's website http://courts.phila.gov 01-101 (Reverse) American LegalNet, Inc. www.FormsWorkFlow.com