Civil Cover Sheet {01-101}

For Office of Judicial Records Use Only (Docket Number) PLAINTIFF'S NAME DEFENDANT'S NAME PLAINTIFF'S ADDRESS DEFENDANT'S ADDRESS PLAINTIFF'S NAME DEFENDANT'S NAME PLAINTIFF'S ADDRESS DEFENDANT'S ADDRESS PLAINTIFF'S NAME DEFENDANT'S NAME PLAINTIFF'S ADDRESS DEFENDANT'S ADDRESS TOTAL NUMBER OF PLAINTIFFS TOTAL NO. OF DEFENDANTS COMMENCEMENT OF ACTION Complaint Petition Action Notice of Appeal Writ of Summons Transfer From Other Jurisdictions AMOUNT IN CONTROVERSY $50,000.00 or less More than $50,000.00 COURT PROGRAMS Arbitration Mass Tort Minor Court Appeal Settlement Jury Savings Action Statutory Appeals Minors Non-Jury Petition Commerce (Completion of W/D/Survival Addendum Required) Other: CASE TYPE AND CODE (SEE INSTRUCTIONS) STATUTORY BASIS FOR CAUSE OF ACTION (SEE INSTRUCTIONS) RELATED PENDING CASES (LIST BY CASE CAPTION AND DOCKET NUMBER) IS CASE SUBJECT TO COORDINATION ORDER? Yes No TO THE OFFICE OF JUDICIAL RECORDS: Kindly enter my appearance on behalf of Plaintiff/Petitioner/Appellant: Papers may be served at the address set forth below. NAME OF PLAINTIFF'S/PETITIONER'S/APPELLANT'S ATTORNEY ADDRESS (SEE INSTRUCTIONS) PHONE NUMBER FAX NUMBER SUPREME COURT IDENTIFICATION NO. E-MAIL ADDRESS SIGNATURE DATE Court of Common Pleas of Philadelphia County Trial Division Civil Cover Sheet 01-101 (Rev. 8/2014) American LegalNet, Inc. www.FormsWorkFlow.com 5M Money Judgment 1C Contract 2D Dental 5L Landlord and Tenant 1T Construction 4L Legal 5D 5E Denial Open Default Judgment Code Enforcement 1O Tort Other: 2M 4Y Medical Other: 5Q Liquor Control Board 2V Motor Vehicle Accident 3R Rent, Lease, Ejectment 5R Board of Revision of Taxes 2H Other T raffic Accident Q1 Quiet Title 5X 5Z Tax Assessment Boards Zoning Board 1F 4M No Fault Benefits Motor Vehicle Property Damage 3D Mortgage Foreclosure - Residential Owner Occupied 52 Board of View 2F Personal Injury - FELA 3F Mortgage Foreclosure - Not Residential 51 Other: 2O Other Personal Injury Not Owner Occupied Instructions for Completing Civil Cover Sheet Rules of Court require that a Civil Cover Sheet be attached to any document commencing an action (whether the action is commenced by Complaint, Writ of Summons, Notice of Appeal, or by Petition). The information requested is necessary to allow the Court to properly monitor, control and dispose cases filed. A copy of the Civil Cover Sheet must be attached to service copies of the document commencing an action. The attorney or non-represented party filing a case shall complete the form as follows: A. Parties i. Plaintiffs/Defendants Enter names (last, first, middle initial) of plaintiff, petitioner or appellant ("plaintiff") and defendant. If the plaintiff or defendant is a government agency or cor- poration, use the full name of the agency or corporation. In the event there are more than three plaintiffs and/or three defendants, list the additional parties on the Supplemental Parties Form. Husband and wife are to be listed as separate parties. ii. Parties' Addresses Enter the address of the parties at the time of filing of the action. If any party is a corporation, enter the address of the registered office of the corporation. iii. Number of Plaintiffs/Defendants: Indicate the total number of plaintiffs and total number of defendants in the action. B. Commencement Type: Indicate type of document filed to commence the action. C. Amount in Controversy: Check the appropriate box. D. Court Program: Check the appropriate box. E. Case Types: Insert the code number and type of action by consulting the list set forth hereunder. To perfect a jury trial, the appropriate fees must be paid as provided by rules of court. Proceedings Commenced by Appeal Actions Commenced by Writ of Summons or Complaint Minor Court Contract Professional Malpractice Other: Local Agency 5B Motor Vehicle Suspension - Breathalizer 5V Motor Vehicle Licenses, Inspections, Insurance 5C Civil Service 5K Philadelphia Parking Authority 2B Assault and Battery 2L Libel and Slander 4F Fraud 1J Bad Faith 2E Wrongful Use of Civil Process Other: Negligence 1G Subrogation Equity E1 No Real Estate E2 Real Estate 1D Declaratory Judgment M1 Mandamus Real Property Other: Proceedings Commenced by Petition 8P Appointment of Arbitrators 8C Name Change - Adult 8L Compel Medical Examination 8D Eminent Domain 8E Election Matters 8F Forfeiture 8S Leave to Issue Subpoena 8M Mental Health Proceedings 8G Civil Tax Case - Petition Other: F. Commerce Program 2S Premises Liability - Slip & Fall 2P Product Liability 2T Toxic Tort T1 Asbestos TZ DES T2 Implant 3E Toxic Waste Other: 1L Mechanics Lien P1 Partition Prevent Waste 1V Replevin 1H Civil Tax Case - Complaint Other: Commencing January 3, 2000 the First Judicial District instituted a Commerce Program for cases involving corporations and corporate law issues, in general. If the action involves corporations as litigants or is deemed a Commerce Program case for other reasons, please check this block AND complete the information on the "Commerce Program Addendum". For further instructions, see Civil Trial Division Administrative Docket 01 of 2000. G. Statutory Basis for Cause of Action If the action is commenced pursuant to statutory authority ("Petition Action"), the specific statute must be identified. H. Related Pending Cases All previously filed related cases, regardless of whether consolidated by Order of Court or Stipulation, must be identified. I. Plaintiff's Attorney The name of plaintiff's attorney must be inserted herein together with other required information. In the event the filer is not represented by an attorney, the name of the filer, address, the phone number and signature is required. The current version of the Civil Cover Sheet may be downloaded from the FJD's website http://courts.phila.gov 01-101 (Reverse) American LegalNet, Inc. www.FormsWorkFlow.com