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### Appellate Docket Number: Appellate Case Style: Vs. Companion Case(s): Amended/Corrected Statement 

## DOCKETING STATEMENT (C ivi l) Appellate Court: (to be filed in the court of appeals upon perfection of appeal under TRAP 32)

NOTE: Because space for additional parties / attorneys is limited on this form, you can include the information on a separate document. As per TR AP 32.1 and 9.4, please include party’s name and the name, address, email address, telephone number, fax number, if any, and Sta te Bar Number of the party’s lead counsel. If the party is not represented by an attorney, that party’s name, address, telephone number, fax number should be provided

.



### I. Appellant II. Appellant Attorney(s)

- Continued

Person Organization

Na me:

Pro Se
If Pro Se Party , enter the following information:

Address:
City/State/Zip :

Tel. Ext. Fax:

Email: Lead Attorney

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:

Ci ty/State/Zip:

Tel. Ext. Fax:

Email:

Lead Attorney

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:

Lead Attorney

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email: 

### II. Appellant Attorney(s)

Lead Attorney

Name:

Bar N o. Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:

Lead Attorney

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:Page 2 of 11 

### I II . Appell ee I V . Appell ee Attorney(s)

- Continued

Person Organization

Name:

Pro Se
If Pro Se Party , enter the following information:

Address:
City/State/Zip :

Tel. Ext. Fax:

Email: Lead Attorney

Name:

Bar No.
Firm/Agency:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:

Lead Attorney

Name:

Bar No.
Firm/Agency:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:

Lead Attorney

Name:

Bar No.
Firm/Agency:

Address 1:

Ad dress 2:
City/State/Zip:

Tel. Ext. Fax:

Email: 

### I V . Appell ee Attorney(s)

Lead Attorney

Name:

Bar No.
Firm/Agency:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:

Lead Attorney

Name:

Bar No.
Firm/Agency:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:Page 3 of 11 

### V. Perfection of Appeal, Judgment and Sentencing

Nature of Case (Subject matter or type of case):
Date Order or Judgment signed: Type of Judgment:
Date Notice of Appeal filed in Trial Court:
If mailed to the Trial Court clerk, also give the date mailed:
Interlocutory appeal of appealabl e order: Yes No
If yes, please specify statutory or other basis on which interlocutory order is appealable (See TRAP 28):

Accelerated Appeal (See TRAP 28 ): Yes No
If yes, please specify statutory or other basis on which appeal is accelerated :

Parental Termination or Child Protection? (See TRAP 28 .4 ): Yes No
Permissive? (See TRAP 28.3 ): Yes No
If yes, please specify statutory or other basis for such status :

A greed? (See TRAP 28 .2 ): Yes No
If yes, please specify statutory or other basis for such status :

Appeal should receive precedence, preference, or priority under statut e or rule? Yes No
If yes, please specify statutory or other basis for such status:

Does this case involve an amount under $100,000? Yes No
Judgment or Order disposes of all parties and issues? Yes No
Appeal from final judgment? Yes No

Does the appeal involve the constitutionality or the validity of a statute, rule, or ordinance? If yes, you must also complete and file the Challenge to Constitutionality of a State Statute form. Yes No



### VI. Actions Extending Time to Perfect Appeal

Motion for New Trial: Yes No If y es, date f iled:

Motion to Modify Judgment: Yes No If y es, date filed:
Request for Findings of Fact and Conclusions of Law:

Yes No If yes, date filed:

Motion to Reinstate : Yes No If yes, date filed:

Motion under TR CP 306a: Yes No If yes, date filed:

Other: Yes No
If Other, please specify:Page 4 of 11 

### V II

. Indigency of Party (Attach file stamped copy of Statement and copy of the trial court order. )

Yes No

Yes No

Yes No Was S t atement of Inability to P a y C ou rt C ost s f i led in the tr i al c ou rt?

I f yes, d at e filed:

Was a M otion C hallenging th e S tatement f iled in the tr ial c ourt?

I f yes, d at e filed:

Was t here a ny h earing o n ap pellant’s ab ility to afford court costs?
Hearing Date:
Did trial court sign an order under Texas Rule of Civil Procedure 145? Yes No

Da te o f Order :

If yes, tr ial court finding: C hallenge Sustained O verruled

VI I I. Bankruptcy
Has any party to the court’s judgment filed for protection in bankruptcy which might affect th is appeal?

Yes No
If yes, please attach a copy of the petition.
Date bankruptcy filed:
Bankruptcy Case Number:

IX . Trial Court and Record

Court:
County:
Trial Court Docket No. ( Cause No.):

Trial Court Judge (who tried or disposed of the case):

Name:

Address 1:

Addr ess 2:
City/State/Zip:

Tel. Ext. Fax:

Email: 

### Clerk’s Record

Trial Court Cler k: District County
Was Clerk’s record requested? Yes No

If y es, date requested:

If no, date it will be requested:
Were payment arrangements made with clerk?

Yes No Indigent
(Note: No request r equired under TRAP 34.5(a),(b).)Page 5 of 11 

### IX . Trial Court and Record

- Continued
Reporter’s or Recorder’s Record
Is there a Reporter’s Record? Yes No

Was Reporter’s R ecord requested? Yes No
If yes, date requested:

If no , date it will be requested : Was the Reporter’s Record electronically recorded? Yes No
Were payment arrangements made with the court reporter/court recorder? Yes No Indigent

Court Reporter Court Recorder Offi cial Substitu te

Name:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:



### Email: Court Reporter Court Recorder Official Substitute

Name:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:



### Email:

X

. Supersedeas Bond
Supersedeas bond filed? Yes No
If yes, date filed:

If no, w ill file? Yes No

X I. Ex traordinary Relief
Will you request extraordinary relief (e.g., temporary or ancillary relief) from this Court? Yes No
If yes, briefly state the basis for your request:Page 6 of 11 

### X II. Alternative Dispute Resolution/Mediation (Complete sectio n if filing in the 1 st 

### , 2 nd 

### , 4 th 

### , 5 th 

### , 6 th 

### , 8 th 

### , 10 th 

### , 11 th 

### , 13 th 

### , or 14 th 

### Court of Appeal s. )

Should this appeal be referred to mediation? Yes No
If no, please specify:
Has this case been through an ADR procedure? Yes No
If yes, who was the mediator?
What type of ADR procedure?
At what stage did the case go through ADR ? Pre

- Trial Post

- Trial Other
If other, please specify:
Type of Case?
Give a brief description of the issue to be raised on appeal, the relief sought, and the applicable standard for review, if known (without prejudice to the right to raise additional issues or request additional relief):

How was the case disposed of?
Summary of relief granted, including amount of money judgment, and if any, damages awarded.
If money judgment, what was the amount? Actual damages:
Punitive (or similar) damages:
Attorney’s fees (trial):
Attorney’s fees (appellate):

Other:
If other, please specify:
Will you challenge this Court’s jurisdiction? Yes No
Does judgment have language that one or more parties “take nothing”? Yes No

Does judgment have a Mother Hubbard clause? Yes No
Other basis for finality :Page 7 of 11 

### X II. Alternative Dispute Resolution/Mediation

- Continued (Complete section if filing in the 1 st 

### , 2 nd 

### , 4 th 

### , 5 th 

### , 6 th 

### , 8 th 

### , 10 th 

### , 11 th 

### , 13 th 

### , or 14 th 

### Court of Appeals.)
Rate the complexity of the case (use 1 for least and 5 for most complex): 1 2 3 4 5
Please make my answer to the preceding questi ons known to other parties in this case? Yes No
Can the parties agree on an appellate mediator? Yes No
If yes, please give the name, address, telephone, fax, and email address:

Name:

Address:
Telephone: Ext.

Fax:

Email:
Language s other than English in which the mediator should be proficient:

Name of the person filling out mediation section of docketing statement:

X III

. Related Matters List any pending or past related appeals before this, or any other Texas Appellate Court, by Court, Docket, and Style.

Court: Docket:
Style:

Vs.

Court: Docket:
Style:

Vs.

Court: Docket:
Style:

Vs.

Court: Docket:
Style:

Vs.

Court: Docket:
Style:

Vs.

Court: Docket:
Style:

Vs.Page 8 of 11 

### XIV

. P ro Bono Program: (Complete section if filing in the 1 st 

### , 2 nd 

### , 3 rd 

### , 5 th 

### , 7 th 

### , 13 th 

### or 14 th 

### Court of Appeals.)

The Courts of Appeals listed above, in conjunction with the State Bar of Texas Appellate Section Pro Bono Committee and local Bar Association s, are conducting a program to place a limited number of civil appeals with appellate counsel who will represent the appellant in the appeal before this Court.
The Pro Bono Committee is solely responsible for screening and selecting the civil cases for in clusion in the Program based upon a number of discretionary criteria, including the financial means of the appellant or appellee. If a case is selected by the Committee, and can be matched with appellate counsel, that counsel will take over representation of the appellant or appellee without charging legal fees. More information regarding this program can be found in the Pro Bono Program Pamphlet available in paper form at the Clerk's Office or on the Internet at htt p://www.tex -app.org . If your case is selected and matched with a volunteer lawyer, you will receive a letter from the Pro Bono Committee within thirty (30) to forty

- five (45) days after submitting this Docketing Statement.
Note: there is no guarantee tha t if you submit your case for possible inclusion in the Pro Bono Program, the Pro Bono Committee will select your case and that pro bono counsel can be found to represent you. Accordingly, you should not forego seeking other counsel to represent you in th is proceeding. By signing your name below, you are authorizing the Pro Bono committee to transmit publicly available facts and information about your case, including parties and background, through selected Internet sites and Listserv to its pool of volun teer appellate attorneys.
Do you want this case to be considered for inclusion in the Pro Bono Program? Yes No
Do you authorize the Pro Bono Committee to contact your trial counsel of record in this matter to answer questions the committee may have regarding the appeal? Yes No
Please note that any such conversations would be maintained as confidential by the Pro Bono Committee and the information used solely for the purposes of considering the case for inclusion in the Pro Bono Prog ram. If you have not previously filed a Statement of Inability to Pay Court Costs and attached a file

- stamped copy of that Statement, does your income exceed 200% of the U.S. Department of Health and Human Services Federal Poverty Guidelines? Yes No
These guidelines can be found in the Pro Bono Program Pamphlet as well as on the internet at http://aspe.hhs.gov/poverty/06poverty.shtml

. Are you willing to disclose your financial circum stances to the Pro Bono Committee? Yes No
If yes, please attach a Statement of Inability to Pay Court Costs completed and executed by the appellant or appellee. Sample forms may be found in the Clerk's Office or on the internet at http://www.tex -app.org . Your participation in the Pro Bono Program may be conditioned upon your execution of a Statement under oath as to your financial circumstances.

Give a brief description of the issues to be raised on appeal, the relief sought, and the applicable standard of review, if known (without prejudice to the right to raise additional issues or request additional relief; use a separate attachment, if necessary).Page 9 of 11 

### X V

. Signature

Signature of couns el (or Pro Se Party) Date

Printed Name State Bar No.

Electronic Signature (Optional) Name



### X V I. Certificate of Service The undersigned counsel certifies that this Docketing Statement has been served on the following lead counsel for all

par ties to the Trial Court’s Order or Judgment as follows on:

Signature of counsel (or Pro Se Party) Electronic Signature (Optional)

State Bar No.

Certificate of Service Requirements (TRAP 9.5(e)): A certificate of service must be signed by the person who made the service and

must state: (1) the date and manner of service; (2) the name and address of each person served, and (3) if the person served is a party’s attorney, the name of the party represented by the attorney.Page 10 of 11 

### Please enter the following for ea ch person served:

Date Served:

Manner Served:

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:
Party: Date Served:

Manner Served:

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:
Party:

Date Served:

Manner Served:

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:
Party: Date Served:

Manner Served:

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Em ail:
Party:

Date Served:

Manner Served:

Name:

Bar No.
Firm/Agency :

Address 1:

Address 2:
City/State/Zip:

Tel. Ext. Fax:

Email:
Party:Page 11 of 11 

### P lease enter the following for each person served that is not an attorney for a party:

Date Served:

Manner Served:

Name:

Address 1:

Address 2: City/State/Zip:

Tel. Ext.

Fax:

Email: Date Served:

Manner Served:

Name:

Address 1:

Address 2: City/State/Zip:

Tel. Ext.

Fax:

Email:

Date Served:

Manner Served:

Name:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext.

Fax:

Email: Date Served:

Manner Served:

Name:

Address 1:

Address 2:
City/State/Zip:

Tel. Ext.

Fax:

Email:

Date Served:

Manner Served:

Name:

Address 1:

Address 2: City/State/Zip:

Tel. Ext.

Fax:

Email: Date Served:

Manner Served:

Name:

Address 1:

Address 2: City/State/Zip:

Tel. Ext.

Fax:

Email: