Revised 7/3/17 DOCKETING STATEMENT FOR CIVIL APPEALS (Return form to the Appellate Court Clerk222s Office within 15 days) Case Style: Appeal No.: Court Appealed to: Court of Appeals Supreme Court (Workers222 Compensation cases are appealed to the Supreme Court) Appellant: County/Court: Trial Judge: Trial Court Number(s): 1. Nature of case: Juvenile Termination of Parental Rights Workers222 Compensation Other 2. Jurisdiction: A. Date of entry of judgment appealed from: B. Is the order appealed from a final order, i.e., does it dispose of the action as to all claims by the parties? C. If the judgment/order is not a final disposition as to all claims by all parties, did the trial judge direct the entry of judgment in accordance with T.R. Civ.P. 54.02? Date of order, if applicable: D. Date of any post-trial motion filed: E. Date of disposition of any post-trial motion filed: F. Will there be: Transcript of Evidence Statement of Evidence Neither 3. Concise statement of the issues proposed to be raised. You are not bound by this statement. Avoid general statements such as 223the judgment is not supported by the evidence224. (Use reverse side if necessary) Name of Party Represented Attorney for Appellant Date: BPR#: Phone: () American LegalNet, Inc. www.FormsWorkFlow.com