Supreme Court of Pennsylvania Court of Common Pleas Civil Cover Sheet For Prothonotary Use Only: TIM ES Docket No: TA _______________________________ County MP The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service of pleadings or other papers as required by law or rules of court. S E C T I O N A Commencement of Action: Complaint Writ of Summons Transfer from Another Jurisdiction Petition Declaration of Taking Lead Plaintiff’s Name: Lead Defendant’s Name: Are money damages requested? Yes No Dollar Amount Requested: (check one) Is this a Class Action Suit? Yes No Is this an MDJ Appeal? within arbitration limits outside arbitration limits Yes No Name of Plaintiff/Appellant’s Attorney: _____________________________________________________________________ Check here if you have no attorney (are a Self-Represented [Pro Se] Litigant) Nature of the Case: Place an “X” to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that you consider most important. TORT (do not include Mass Tort) S E C T I O N B Intentional Malicious Prosecution Motor Vehicle Nuisance Premises Liability Product Liability (does not include mass tort) Slander/Libel/ Defamation Other: _________________________ _________________________ MASS TORT Asbestos Tobacco Toxic Tort - DES Toxic Tort - Implant Toxic Waste Other: _________________________ _________________________ PROFESSIONAL LIABLITY Dental Legal Medical Other Professional: _________________________ _________________________ CONTRACT (do not include Judgments) Buyer Plaintiff Debt Collection: Credit Card Debt Collection: Other ________________________ ________________________ Employment Dispute: Discrimination Employment Dispute: Other ________________________ ________________________ Other: ________________________ ________________________ REAL PROPERTY Ejectment Eminent Domain/Condemnation Ground Rent Landlord/Tenant Dispute Mortgage Foreclosure: Residential Mortgage Foreclosure: Commercial Partition Quiet Title Other: ________________________ ________________________ CIVIL APPEALS Administrative Agencies Board of Assessment Board of Elections Dept. of Transportation Statutory Appeal: Other _________________________ _________________________ Zoning Board Other: _________________________ _________________________ MISCELLANEOUS Common Law/Statutory Arbitration Declaratory Judgment Mandamus Non-Domestic Relations Restraining Order Quo Warranto Replevin Other: _________________________ _________________________ Updated 1/1/2011 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE Pennsylvania Rule of Civil Procedure 205.5. (Cover Sheet) provides, in part: Rule 205.5. Cover Sheet (a)(1) This rule shall apply to all actions governed by the rules of civil procedure except the following: (i) actions pursuant to the Protection from Abuse Act, Rules 1901 et seq. (ii) actions for support, Rules 1910.1 et seq. (iii) actions for custody, partial custody and visitation of minor children, Rules 1915.1 et seq. (iv) actions for divorce or annulment of marriage, Rules 1920.1 et seq. (v) actions in domestic relations generally, including paternity actions, Rules 1930.1 et seq. (vi) (2) voluntary mediation in custody actions, Rules 1940.1 et seq. At the commencement of any action, the party initiating the action shall complete the cover sheet set forth in subdivision (e) and file it with the prothonotary. (b) The prothonotary shall not accept a filing commencing an action without a completed cover sheet. (c) The prothonotary shall assist a party appearing pro se in the completion of the form. (d) A judicial district which has implemented an electronic filing system pursuant to Rule 205.4 and has promulgated those procedures pursuant to Rule 239.9 shall be exempt from the provisions of this rule. (e) The Court Administrator of Pennsylvania, in conjunction with the Civil Procedural Rules Committee, shall design and publish the cover sheet. The latest version of the form shall be published on the website of the Administrative Office of Pennsylvania Courts at www.pacourts.us. American LegalNet, Inc. www.FormsWorkFlow.com