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 Garnishment�Federal�180 days Garnishment�Wage�180 days Garnishment�Other � 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