Free Civil Appeal Statement - Georgia

Rev. 6/98

UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT CIVIL APPEAL STATEMENT
11th Circuit Docket Number:________________________________ DISTRICT: NAME OF JUDGE: DATE COMPLAINT FILED: DISTRICT COURT DOCKET NUMBER: DATE NOTICE OF APPEAL FILED: IS THIS A CROSS-APPEAL? 9 Yes 9 No

Please TYPE. Attach additional pages if necessary. TITLE IN FULL:

HAS THIS MATTER BEEN BEFORE THIS COURT PREVIOUSLY? 9 Yes 9 No IF YES, PROVIDE: (A) CASE NAME (B) CITATION (C) DOCKET NUMBER ATTORNEY NAME FOR APPELLANT: 9 Plaintiff 9 Defendant 9 Other (Specify) FOR APPELLEE: 9 Plaintiff 9 Defendant 9 Other (Specify) MAILING ADDRESS TELEPHONE AND FAX

Circle/check/complete those items below and on page 2 that apply. JURISDICTION Federal Question Diversity US Plaintiff US Defendant NATURE OF JUDGMENT Final Judgment, 28 USC 1291 Interlocutory Order, 28 USC 1292(a)(1) Interlocutory Order Certified, 28 USC 1292(b) Interlocutory Order, Qualified Immunity Final Agency Action (Review) 54(b) NATURE OF SUIT ( 9 Class Action ) Admiralty-Maritime Antitrust Arbitration Assault Banking Bankruptcy Civil Rights 9 Title VII 9 ADA 9 ADEA 9 IDEA 9 Harassment 9 1983 9 Other
Commercial Contract

TYPE OF ORDER Dismissal/Jurisdiction Default Judgment Summary Judgment Judgment/Bench Trial Judgment/Jury Verdict Judgment/Directed Verdict/NOV Injunction Other _________________________

RELIEF Damages: Amount Sought by Plaintiff: $__________________ Amount Sought by Defendant: $__________________ Awarded $__________________ to ________________________ Injunctions: 9 TRO 9 Preliminary 9 Permanent

9 Granted 9 Denied

Commodities Communications Consumer Counsel Fee Election Energy

Attorney Disqualification

Copyright/TM/Patent Employment Contract

Environment ERISA FELA Finance FOI Forfeiture Fraud FTCA Indemnity

Insurance

Negotiable Instrument

Personal Injury Privacy Real Property Securities Stockholder Slander/Libel

Review Agency Action

Social Security Tax TILA US Constitution Warranty Other Contract Other Tort

Other Statutory Action

Page 2 GENERAL BASED ON YOUR PRESENT KNOWLEDGE: (1)

11th Circuit Docket Number: ________________________________

DOES THIS APPEAL INVOLVE A QUESTION OF FIRST IMPRESSION? WHAT IS THE ISSUE YOU CLAIM IS ONE OF FIRST IMPRESSION?

9 Yes

9 No

(2)

WILL THE DETERMINATION OF THIS APPEAL TURN ON THE INTERPRETATION OR APPLICATION OF A PARTICULAR CASE OR STATUTE? 9 Yes 9 No IF YES, PROVIDE: (A) CASE NAME/STATUTE (B) CITATION (C) DOCKET NUMBER, IF UNREPORTED IS THERE ANY CASE NOW PENDING OR ABOUT TO BE BROUGHT BEFORE THIS COURT OR ANY OTHER COURT OR ADMINISTRATIVE AGENCY THAT: (A) ARISES FROM SUBSTANTIALLY THE SAME CASE OR CONTROVERSY AS THIS APPEAL? 9 Yes 9 No (B) INVOLVES AN ISSUE THAT IS SUBSTANTIALLY THE SAME, SIMILAR, OR RELATED TO AN ISSUE IN THIS APPEAL? 9 Yes 9 No IF YES, PROVIDE: (A) CASE NAME (B) CITATION (C) DOCKET NUMBER, IF UNREPORTED (D) COURT OR AGENCY WILL THIS APPEAL INVOLVE A CONFLICT OF LAW: (A) WITHIN THE ELEVENTH CIRCUIT? 9 Yes 9 No (B) AMONG CIRCUITS? 9 Yes 9 No IF YES, EXPLAIN BRIEFLY:

(3)

(4)

ISSUES PROPOSED TO BE RAISED ON APPEAL, INCLUDING JURISDICTIONAL CHALLENGES:

I CERTIFY THAT I SERVED THIS CIVIL APPEAL STATEMENT ON THE CLERK OF THE U.S. COURT OF APPEALS FOR THE ELEVENTH CIRCUIT AND SERVED A COPY ON EACH PARTY OR THEIR COUNSEL OF RECORD, THIS _________ DAY OF ___________________, _________.

_____________________________________________________
NAME OF COUNSEL (TYPE)

_____________________________________________________
SIGNATURE OF COUNSEL

ATTACH portion of district court, tax court, or agency record described in 11th Cir. R. 33-1(b) (judgments and orders appealed from or sought to be reviewed; any supporting opinion, findings of fact, and conclusions of law filed by the court or the agency, board, commission, or officer; any report and recommendation adopted by an order; findings and conclusions of an administrative law judge when appealing a court order reviewing an agency determination; any agency docket sheet or record index).