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STATE OF SOUTH CAROLINA

) ) COUNTY OF ______________________________ ) ) ____________________________________________ ) Plaintiff(s) ) ) vs. ) ) ____________________________________________ ) Defendant(s) )
(Please Print) Submitted By: ____________________________________ Address: _________________________________________ _____________________________________________________ _____________________________________________________

IN THE COURT OF COMMON PLEAS

CIVIL ACTION COVERSHEET
__________-CP - ______- __________

SC Bar #: Telephone #: Fax #: Other: E-mail:

_______________________________ _______________________________ _______________________________ _______________________________ _______________________________

NOTE: The cover sheet and information contained herein neither replaces nor supplements the filing and service of pleadings or other papers as required by law. This form is required for the use of the Clerk of Court for the purpose of docketing. It must be filled out completely, signed, and dated. A copy of this cover sheet must be served on the defendant(s) along with the Summons and Complaint.

DOCKETING INFORMATION (Check all that apply)

*If Action is Judgment/Settlement do not complete JURY TRIAL demanded in complaint. NON-JURY TRIAL demanded in complaint. This case is subject to ARBITRATION pursuant to the Court Annexed Alternative Dispute Resolution Rules. This case is subject to MEDIATION pursuant to the Court Annexed Alternative Dispute Resolution Rules. This case is exempt from ADR. (Proof of ADR/Exemption Attached) NATURE OF ACTION (Check One Box Below)
Contracts Constructions (100) Debt Collection (110) Employment (120) General (130) Breach of Contract (140) Other (199) _____________________ Torts - Professional Malpractice Dental Malpractice (200) Legal Malpractice (210) Medical Malpractice (220) Previous Notice of Intent Case # 20____-CP-_____-_____________ Notice/ File Med Mal (230) Other (299) _______________________ Torts ­ Personal Injury Assault/Slander/Libel (300) Conversion (310) Motor Vehicle Accident (320) Premises Liability (330) Products Liability (340) Personal Injury (350) Wrongful Death (360) Other (399) _________________________ Real Property Claim & Delivery (400) Condemnation (410) Foreclosure (420) Mechanic's Lien (430) Partition (440) Possession (450) Building Code Violation (460) Other (499) _______________________

Inmate Petitions PCR (500) Mandamus (520) Habeas Corpus (530) Other (599) ___________________

Judgments/Settlements Death Settlement (700) Foreign Judgment (710) Magistrate's Judgment (720) Minor Settlement (730) Transcript Judgment (740) Lis Pendens (750) Transfer of Structured Settlement Payment Rights Application (760) Other (799) _____________ Special/Complex /Other Environmental (600) Pharmaceuticals (630) Automobile Arb. (610) Unfair Trade Practices (640) Medical (620) Out-of State Depositions (650) Other (699) Sexual Predator (510) ___________________

Administrative Law/Relief Reinstate Driver's License (800) Judicial Review (810) Relief (820) Permanent Injunction (830) Forfeiture-Petition (840) Forfeiture--Consent Order (850) Other (899) ________________________

Appeals Arbitration (900) Magistrate-Civil (910) Magistrate-Criminal (920) Municipal (930) Probate Court (940) SCDOT (950) Worker's Comp (960) Administrative Law Judge (980)

Public Service Commission (990) Employment Security Comm (991) Other (999) ___________________________

Submitting Party Signature:

Date:
Frivolous

Note: Frivolous civil proceedings may be subject to sanctions pursuant to SCRCP, Rule 11, and the South Carolina
Civil Proceedings Sanctions Act, S.C. Code Ann. §15-36-10 et. seq.

SCCA / 234 (07/09)

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FOR MANDATED ADR COUNTIES ONLY Allendale, Anderson, Beaufort, Colleton, Florence, Greenville, Hampton, Horry, Jasper, Lexington, Pickens (Family Court Only), and Richland
SUPREME COURT RULES REQUIRE THE SUBMISSION OF ALL CIVIL CASES TO AN ALTERNATIVE DISPUTE RESOLUTION PROCESS, UNLESS OTHERWISE EXEMPT. You are required to take the following action(s): 1. The parties shall select a neutral and file a "Proof of ADR" form on or by the 210th day of the filing of this action. If the parties have not selected a neutral within 210 days, the Clerk of Court shall then appoint a primary and secondary mediator from the current roster on a rotating basis from among those mediators agreeing to accept cases in the county in which the action has been filed. 2. The initial ADR conference must be held within 300 days after the filing of the action. 3. Pre-suit medical malpractice mediations required by S.C. Code §15-79-125 shall be held not later than 120 days after all defendants are served with the "Notice of Intent to File Suit" or as the court directs. (Medical malpractice mediation is mandatory statewide.) 4. Cases are exempt from ADR only upon the following grounds: a. Special proceeding, or actions seeking extraordinary relief such as mandamus, habeas corpus, or prohibition; b. Requests for temporary relief; c. Appeals d. Post Conviction relief matters; e. Contempt of Court proceedings; f. Forfeiture proceedings brought by governmental entities;

g. Mortgage foreclosures; and h. Cases that have been previously subjected to an ADR conference, unless otherwise required by Rule 3 or by statute. 5. In cases not subject to ADR, the Chief Judge for Administrative Purposes, upon the motion of the court or of any party, may order a case to mediation. 6. Motion of a party to be exempt from payment of neutral fees due to indigency should be filed with the Court within ten (10) days after the ADR conference has been concluded. Please Note: You must comply with the Supreme Court Rules regarding ADR. Failure to do so may affect your case or may result in sanctions.

SCCA / 234 (07/09)

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