No If yes, date filed:
Contestfiled in trial court: flves fJ No If yes, date filed:
Date ruling on contestdue:
Ruling on contest: I Sustained fl Ovemrled Date of ruling:
Page3 of9 Hasanypartyto the court'sjudgmentfiled for protectionin bankruptcywhichmightaffectthis appeal? [Ves Xl No If yes,pleaseattacha copyof thepetition.
Date bankruptcy filed:
Court: Clerk'sRecord: County: Trial CourtClerk ffi nistrict fl County Trial Court DocketNumber (CauseNo.): Wasclerk'srecordrequested? ffiYes [No If yes, daterequested: Trial Judge(who tried or disposedof case): If no, date it will be requested: First Name: Were payment arrangementsmade with clerk? Middle Name: ffiYes f]No firndigent Last Name: (Note:No requestrequired under TRAP 34.5(a),(b)) Suffix:
Address l:
Address2 : City: State:W Zip + 4: Telephone: ext. ffi Fax: Email:
Reporter's or Recorder'sRecord:
Is there a reporteCsrecord? ffiYes fl No Wasreportelsrecordrequested? ffiVes I No
Wastherea reporter's recorded?flYes recordelectronically X If yes, date requested:
lf no, date it will be requested: Werepaymentarrangements madewith the courtreporter/courtrecorder? ffiVes fl WofiIndigent
Page4of 9 ffi CourtReporter I CourtRecorder il omriut il Substitute
First }{ame: Middle Name: Last Name:
Addressl: Address2: City: State Zip + 4: Telephone: ext. ffi Fax: Email:
I CourtReporter n Court Recorder I om"iut n Substitute First Name: Middle Name: Last Name: Suffix: W Address1: Address2: City: State Zip + 4: Telephone: ext. ffi Fax: Email:
Supersedeas fJ No Ifyes, datefiled: ffi Will file: flves il uo
Will you requestextraordinary relief(e.g.temporaryor ancillaryrelief)from thisCourt? [Yes Xl No If yes, briefly statethe basisfor your request:
Should this appealbe referredto mediation? f, Ves X No Page5 of9 If no, pleasespecify: Hasthe casebeenthroughan ADR procedure? flYes X No If yes, who was the mediator? What type of ADR procedure? At what stage did the casego through ADR? flPre-Trial I Post-Trial I Ottrer If other,pleasespeciff: Type ofcase? Give a briefdescriptionofthe issueto be nised on appealthc relief sougl4 andthe applicablestandardfor rcvieq ifknown (without prejudiceto the right to raiscadditionalissuesor requestadditionalrelief):
How was the casedisposedof? Summaryof relief granted,includingamountof moneyjudgment,andif any,damages awarded. If moneyjudgrnent,whatwasthe amount?Actualdamages: Punitive(or similar)damages: ffi Atrorney'sfees(trial)r ffi Attorney's fees(appellate):
If other,pleasespecift:
Will you challengethis Court'sjurisdiction? [Yes X No Doesjudgmenthavelanguagethat oneor moreparties"takenothing"? ffi Yes il Wo Doesjudgmenthavea MotherHubbardclause?[Yes X No Ottrerbasisfor finality? Ratethecomplexityofthecase(uselforleastand5formostcomplex): n1 n2 X3 n4 [S Pleasemakemy answerto theprecedingquestions knownto otherpartiesin this case. ffilYes I No Canthe partiesagre€on an appellatemediator? [ Yes E t to Ifyes, pleasegivename,address, telephone, fax andemailaddress: Name Address Fax Email ffi ffi ffi Languagesother than English in which the mediator should be proficient: Name of person filing out mediation section of docketing statement:
Page6 of 9 List any pending or pastrelated appealsbefore this or any other Texas appellatecourt by court, docket number, and style.
DocketNumber: Trial Court:
Style:
Vs.
FageTof9 XIY. Pro Bsno Progr*m: (Ccmpletesectionif filing in the lsto3rdr Sthoor 14thCpurts of Appeals) The CourtsofAppeals listedabove,in conjunctionwith the StateBar ofTexas AppellateSectionPro Bono Committeeand local Bar Associations, are conducting a program to place a limited number ofcivil appealswith appellate counsel who will representthe appellant in the appeal before this Court.
The Pro Bono Committee is solely responsible for screening and selecting the civil casesfor inclusion in the