IN THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY PENNYSLVANIA CIVIL COVER SHEET Date Filed: __________________________________ Case No: Judge: Plaintiff(s) __________________________________ __________________________________ Counsel of Record: vs. __________________________ Attorney For: ____________________________ PA I.D. No.: ____________________________ Firm: ____________________________________ Address: ____________________________________ ___ ____________________________________ Defendant(s) Phone No. ____________________________________ PLEASE ANSWER ALL OF THE FOLLOWING SECTIONS. I. IS THIS A CIVIL ACTION-MEDICAL PROFESSIONAL YES NO IS THE AMOUNT IN CONTROVERSY LESS THAN $30,000? YES NO DO YOU ANTICIPATE THAT A TRIAL IN THIS CASE YES NO YES NO LIABILITY ACTION? II. III. WILL TAKE MORE THAN 5 DAYS? IV. ARE THERE ANY RELATED CASES PENDING? IF YES, PROVIDE THE CASE No. ________________________ V. DOES THIS CASE INVOLVE A CONSTRUCTION CONTRACT? VI. PLEASE INDICATE IF THE CAUSE OF ACTION IS ONE OF THE FOLLOWING: ASBESTOS LAND USE APPEAL CONDEMNATION TAX CLAIM BUREAU CASE APPEAL BOARD OF ASSESSMENT PETITION TO GARNISH WAGES – LANDLORD/TENANT APPEAL SUSPENSION DRIVER'S LICENSE/ APPEAL SUSPENSION INSPECTION LICENSE STATUTORY APPEAL WRIT OF SEIZURE/COMPLAINT REPLEVIN MOTION/PETITION CHANGE OF NAME STATEMENT OF OBJECTION OTHER _________________________________ VII. To The Prothonotary: Please enter my appearance on behalf of Plaintiff/Petitioner /Appellant. Papers may be served at the address set forth above. Signature: __________________________________ White–Prothonotary Revised 7/3/07 Green–Court Admin. Yellow–Judge YES NO Date: ________________ Pink–Opposing Counsel Gold- Counsel American LegalNet, Inc. www.FormsWorkFlow.com