Appellate Docket Number: ___________________________________________ Appellate Case Style: DOCKETING STATEMENT (CIVIL) Court of Appeals [to be filed in the court of appeals upon perfection of appeal under TRAP 32] I. Parties (TRAP 32.1(a), (e)): Appellant(s): Appellee(s): (See note at bottom of page) (See note at bottom of page) Attorney (lead appellate counsel): Attorney (lead appellate counsel, if known; if not, then trial counsel): Address (lead counsel): Address (lead appellate counsel, if known; if not, then trial counsel): Telephone: (include area code) Telephone: (include area code) Telecopy: (include area code) Telecopy: (include area code) SBN (lead counsel): SBN (lead counsel): If not represented by counsel, provide appellant’s/appellee’s address, telephone number, and telecopy number. On Attachment 1, or a separate attachment if needed, list the same information stated above for any additional parties to the trial court’s judgment. American LegalNet, Inc. www.FormsWorkFlow.com II. Perfection Of Appeal And Jurisdiction (TRAP 32.1(b), (c), (g), (j)): Date order or judgment signed: Date notice of appeal filed in trial court: (Attach a signed copy, if possible) (Attach file-stamped copy; if mailed to the trial court clerk, also give the date of mailing) W hat type of judgment? (e.g., jury trial, bench trial, summary judgment, directed verdict, other (specify)) Interlocutory appeal of appealable order: Yes G No G (Please specify statutory or other basis on which interlocutory order is appealable) (See TRAP 28) If money judgment, what was the amount? Actual damages: Accelerated appeal (See TRAP 28): Yes G No G Punitive (or similar) damages: (Please specify statutory or other basis on which appeal is accelerated) Attorneys’ fees (trial): Attorneys’ fees (appellate): Other (specify): Appeal that receives precedence, preference, or priority under statute or rule? Yes G No G (Please specify statutory or other basis for such status) -2American LegalNet, Inc. www.FormsWorkFlow.com Appeal from final judgment? Yes G No G W ill you challenge this Court’s jurisdiction? If yes, explain. Does judgment dispose of all parties and issues: Yes G No G Does judgment have a Mother Hubbard clause? (E.g.: “All relief not expressly granted is denied”): Yes G No G Does judgment have language that one or more parties “take nothing”? Yes G No G Other basis for finality? III. Actions Extending Time To Perfect Appeal (TRAP 32.1(d)): Filed Check as appropriate Action Motion for New Trial No G Yes G Motion to Modify Judgment No G Yes G No G Yes G Motion to Reinstate No G Yes G Motion under TRCP 306a No G Yes G Other (specify): No G Date Filed Yes G Request for Findings Conclusions of Law IV. of Fact and Indigency Of Party (TRAP 32.1(k)): (Attach file-stamped copy of affidavit) Event Filed Check as appropriate Affidavit filed No G No G N/A Yes G Contest filed Date Yes G Date ruling on contest due: Ruling on contest: Sustained G Overruled G V. Bankruptcy (TRAP 8): W ill the appeal be stayed by bankruptcy? Date bankruptcy filed? Name of bankruptcy court: Bankruptcy Case No.: Style of bankruptcy case: -3American LegalNet, Inc. www.FormsWorkFlow.com VI. Trial Court And Record (TRAP 32.1(c), (h), (i)): Court: County: Trial Court Docket Number (Cause No.): Trial Judge (who tried or disposed of case): Court Clerk (district clerk): Telephone Number: (include area code) Telephone Number: (include area code) Telecopy Number: (include area code) Address: Telecopy Number: (include area code) Address: Clerk’s Record Yes G W ill request G Sworn copy for accelerated appeal Yes W as requested on: (Note: No request required under TRAP 34.5(a), (b)) G (See TRAP 28.3) Court Reporter or Court Recorder: Court Reporter or Court Recorder: Telephone Number: (include area code) Telephone Number: (include area code) Telecopy Number: (include area code) Telecopy Number: (include area code) Address: Address: (Attach additional sheet if necessary for additional court reporters/recorders) Length of trial (approximate): Reporter’s or Recorder’s Record (check if electronic recording G) State arrangements made for payment of court reporter/recorder: None G W ill request G W as requested on: -4American LegalNet, Inc. www.FormsWorkFlow.com VII. Nature Of The Case (TRAP 32.1(f)) (Subject matter or type of case: E.g., personal injury, breach of contract, workers’ compensation, or temporary injunction) (see list below): Administrative/agency _____ Banking Malpractice Legal _____ Medical _____ Other _____ _____ Business _____ Motor Vehicle _____ Condemnation _____ Municipal _____ Consumer/DTPA _____ Oil & Gas _____ Construction _____ Personal Injury _____ Contract _____ Premises Liability _____ Employment/Labor _____ Probate _____ Family _____ Products Liability _____ Custody _____ Real Property _____ Property Division _____ Securities _____ Termination _____ Tax _____ Other _____ U.C.C./Tex. Bus. & Com. Code _____ Fraud _____ Venue _____ Insurance _____ W orkers’ compensation _____ Juvenile _____ Other (specify): _____ Landlord/Tenant _____ None G W ill file G W as filed on: VIII. Supersedeas Bond (TRAP 32.1(1)): IX. Extraordinary Relief: W ill you request extraordinary relief (e.g., temporary or ancillary relief) from this Court? Yes G No G If yes, briefly state the basis for your request. -5American LegalNet, Inc. www.FormsWorkFlow.com X. Pro Bono Pilot Program: The Third Court of Appeals, in conjunction with the State Bar of Texas Appellate Section Pro Bono Committee, is conducting a Pro Bono Pilot Program to place a limited number of civil appeals with appellate counsel who will represent the appellant in the appeal before this Court. The Pro Bono Committee will screen and select the civil cases for inclusion in the Program based upon a number of discretionary criteria, including the financial means of the appellant. If a case is selected by the Committee and can be matched with appellate counsel, that counsel will take over the representation of the appellant without charging legal fees. More information regarding this program can be found in the Third Court of Appeals Pro Bono Pilot Program Pamphlet available in paper form at the Clerk’s Office or on the Internet at http://www.tex-app.org./probono-3rdcourt.php. If your case is selected, and we match your case with one of our volunteer lawyers, you will receive a letter from the Committee within thirty (30) to forty-five (45) days of submitting this Docketing Statement. NOTE: There is no guarantee that, if you submit this case for possible inclusion in the Pro Bono Pilot Program, the Pro Bono Committee will select your case and that pro bono counsel can be found to represent you. Accordingly, you should not forego seeking other counsel to represent you in this proceeding. By signing your name below, you are authorizing the Pro Bono Committee to transmit publicly available facts and information about your case, including parties and background, through selected Internet sites and a Listserv to its pool of volunteer appellate attorneys. 1. Do you want this case to be considered for inclusion in the Pro Bono Pilot Program? Yes ¨ No ¨ If you answered “Yes” to Question X.1, then please answer the following questions. 2. Do you authorize the Pro Bono Committee to contact your trial counsel of record in this matter to answer questions the committee may have regarding the appeal? Please note that the substance of any such conversations would be maintained as confidential by the Pro Bono Committee , to the extent permitted by law. The information would be used solely for the purposes of considering the case for inclusion in the Pro Bono Pilot Program. Yes ¨ No ¨ 3. If you have not previously filed an affidavit of indigency and attached a file-stamped copy of that affidavit, does your income exceed 200% of the U.S. Department of Health and Human Services Federal Poverty Guidelines? These guidelines can be found in the Third Court of Appeals Pro Bono Pilot Program Pamphlet as well as on the Internet at http://aspe.hhs.gov/poverty/08poverty.shtml. Yes ¨ No ¨ 4. Are you willing to disclose your financial circumstances to the Pro Bono Committee? If so, please attach an Affidavit of Indigency completed and executed by the appellant. Forms may be found in the Clerk’s Office or on the Internet at http://www.tex-app.org. Your participation in the Pro Bono Pilot Program may be conditioned upon your execution of an affidavit under oath as to your financial circumstances. Yes ¨ No ¨ -6American LegalNet, Inc. www.FormsWorkFlow.com 5. Give a brief description of the issues to be raised on appeal, the relief sought, and the applicable standard of review, if known (without prejudice to the right to raise additional issues or request additional relief; use a separate attachment, if necessary). XI. Related Matters: List any pending or past related appeals or original proceedings (e.g., mandamus, injunction, habeas corpus) before this or any other Texas appellate court by court, docket number, and style. XII. Any other information requested by the court (see attachments, if any). XIII. Signature: ________________________________________ Date: _________________________ Signature of counsel (or pro se party) State Bar No.:___________________ Printed Name: _____________________________________ -7American LegalNet, Inc. www.FormsWorkFlow.com XIV. Certificate of Service: The undersigned counsel certifies that this docketing statement has been served on the following lead counsel for all parties to the trial court’s order or judgment as follows on ______________________, 19____. ________________________________________ Signature (TRAP 9.5(e) requirements stated below; use additional sheets, if necessary) Note: Certificate of Service Requirements (TRAP 9.5(e)): A certificate of service must be signed by the person who made the service and must state: (1) (2) (3) the date and manner of service; the name and address of each person served; and if the person served is a party’s attorney, the name of the party represented by that attorney. -8American LegalNet, Inc. www.FormsWorkFlow.com