CIVIL CASE INFORMATION STATEMENT CIVIL CASES (Other than Domestic Relations) In the Circuit Court, County, West Virginia I. CASE STYLE: Plaintiff(s) Case # Judge: vs. Defendant(s) Days to Answer Type of Service Street City, State, Zip Street City, State, Zip Street City, State, Zip Street City, State, Zip Original and copies of complaint enclosed/attached. SCA-C100.02 / 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com PLAINTIFF: DEFENDANT: CASE NUMBER: II. TYPE OF CASE: G General Civil G Adoption G Mass Litigation (As defined in T.C.R. Rule XIX (c) G Administrative Agency Appeal G Civil Appeal from Magistrate Court G Miscellaneous Civil Petition G Mental Hygiene G Guardianship G Medical Malpractice G G G G G G G Asbestos Carpal Tunnel Syndrome Diet Drugs Environmental Industrial Hearing Loss Silicone Implants Other: G G III. Habeas Corpus/Other Extraordinary Writ Other: JURY DEMAND: G Yes G No CASE WILL BE READY FOR TRIAL BY (MONTH/YEAR): _______/_______ IV. DO YOU OR ANY OF YOUR CLIENTS OR WITNESSES IN THIS CASE REQUIRE SPECIAL ACCOMMODATIONS DUE TO A DISABILITY? G YES G NO IF YES, PLEASE SPECIFY: G Wheelchair accessible hearing room and other facilities G Interpreter or other auxiliary aid for the hearing impaired G Reader or other auxiliary aid for the visually impaired G Spokesperson or other auxiliary aid for the speech impaired G Other:_______________________________________________________________________ Attorney Name: Representing: Firm: G Plaintiff Address: G Cross-Complainant G Cross-Defendant G Defendant Telephone: Dated: Signature G Proceeding Without an Attorney SCA-C100.02 / 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com