FAIRFAX CIRCUIT COURT CIVIL CASE COVERSHEET Parties: Plaintiffs 1. 2. 3. 1. 2. 3. Defendants *Plaintiff proceeding without Counsel ­ Address and Daytime Phone Number required on Complaint Plaintiff Attorney: Name: Firm: Street: City: Phone Number: E-mail Address: State: Zip: Fax Number: Bar ID: Nature of Complaint (Check only one) * Cases in the Civil Tracking Program Administrative Appeal Affirmation of Marriage Aid & Guidance Appeal Decision of Board of Zoning Appeal of Process/Judicial Appeal Appointment Church/Organization Trustees Arbitration Attachment Complaint ­ Equity * Complaint ­ Legal Cause of Action * Compromise Settlement Condemnation* Confession of Judgment Construction * Contract * Conversion* Court Satisfaction of Judgment Declare Death Declaratory Judgment * Defamation * Delinquent Taxes * Eminent Domain Encumber/Sell Real Estate Erroneous Assessments Expungement False Arrest/Imprisonment* Malpractice ­ Medical * Mechanics/Vendors Lien * Partition * Personal Injury ­ Assault * Personal Injury ­ Auto * Personal Injury ­ Emotional * Personal Injury ­ Premises Liability* Property Damage* Products Liability* Quiet Title * Real Estate * Restoration of Driving Privilege Vital Record Correction Writ Habeas Corpus Writ Mandamus Wrongful Death* Wrongful Discharge * OTHER: Fiduciary/Estate Complaint Garnishment­Federal­180 days Garnishment­Wage­180 days Garnishment­Other ­ 90 days Guardian/Conservator Adult Guardianship/Minor Injunction Interpleader Insurance * Judicial Review Malicious Prosecution * Malpractice ­ Legal * Damages in the amount of $ ___________________ are claimed. Requested Service: Sheriff Private Process Server DMV Secretary of Commonwealth State Corporation Commission Publication No Service at this time CCR D-90 Civil Coversheet (Revised ­ October 2011) American LegalNet, Inc. www.FormsWorkFlow.com