Civil Docketing Statement Form – Fill Out and Use This PDF

V. Perfection Of Appeal And Jurisdiction

Nature of Case (Subject matter or type of case):

Date order or judgment signed:

Date notice of appeal filed in trial court:

If mailed to the trial court clerk, also give the date mailed:

Interlocutory appeal of appealable 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:
Agreed? (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 statute 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?							Yes	No
VI. Actions Extending Time To Perfect Appeal
Motion for New Trial:	Yes	No	If yes, date filed:
Motion to Modify Judgment:	Yes	No	If yes, date filed:
Request for Findings of Fact	Yes	No	If yes, date filed:
and Conclusions of Law:
Motion to Reinstate:	Yes	No	If yes, date filed:
Motion under TRCP 306a:	Yes	No	If yes, date filed:
Other:	Yes	No
If other, please specify:

VII. Indigency Of Party: (Attach file-stamped copy of Statement, and copy of the trial court order.)

Was Statement of Inability to Pay Court Costs filed in the trial court?				Yes	No	If yes, date filed:
Was a Motion Challenging the Statement filed in the trial court?				Yes	No	If yes, date filed:
Was there any hearing on appellant's ability to afford court costs?				Yes	No	Hearing date:
Did trial court sign an order under Texas Rule of Civil Procedure 145?				Yes	No	Date of order:
If yes, trial court finding:		Challenge Sustained		Overruled

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VIII. Bankruptcy

Has any party to the court's judgment filed for protection in bankruptcy which might affect this appeal?			Yes		No
If yes, please attach a copy of the petition.
Date bankruptcy filed:	Bankruptcy Case Number:

IX. Trial Court And Record

Reporter's or Recorder's Record:
Is there a reporter's record?	Yes	No
Was reporter's record requested?	Yes	No
Was there a reporter's record electronically recorded?			Yes	No
If yes, date requested:
If no, date it will be requested:
Were payment arrangements made with the court reporter/court recorder?					Yes	No Indigent

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

Languages other than English in which the mediator should be proficient:

Name of person filing out mediation section of docketing statement:

XIII. Related Matters

List any pending or past related appeals before this or any other Texas appellate court by court, docket number, and style.

Docket Number:Trial Court:

Style:

Vs.

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XIV. Pro Bono Program: (Complete section if filing in the 1st, 2nd, 3rd, 5th, 13th or 14th Courts of Appeals)

The Courts of Appeals listed above, in conjunction with the State Bar of Texas Appellate Section Pro Bono Committee and local Bar Associations, 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 inclusion 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 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 that 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 this 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 volunteer 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 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 Program.

If you have not previously filed an 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 circumstances to the Pro Bono Committee? Yes No

If yes, please attach an 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).

XV. Signature

Signature of counsel (or pro se party)	Date:
Printed Name:	State Bar No.:
Electronic Signature:
(Optional)

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XVI. Certificate of Service

The undersigned counsel certifies that this docketing statement has been served on the following lead counsel for all parties to the trial

court's order or judgment as follows on	.
Signature of counsel (or pro se party)	Electronic Signature:
	(Optional)
Person Served	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 that attorney

Please enter the following for each person served:

Date Served:

Manner Served:

First Name:

Middle Name:

Last Name:

Suffix:

Law Firm Name:

Address 1:

Address 2:

City:

StateZip+4:

Telephone:ext.

Fax:

Email:

If Attorney, Representing Party's Name:

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