Case Information
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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:
D. Trial Court And Record:
Court: Clerk's Record: County: Trial Court Docket Number (Cause No.):
Trial Judge (who tried or disposed of case): First Name: Middle Name: Last Name: Suffix: Address 1: Address 2: City: State: Telephone: Fax: Email:
Reporter's or Recorder's Record:
Is there a reporter's record? 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 clerk? Yes No Indigent (Note: No request required under TRAP 34.5(a),(b))
Yes No
Was there a reporter's record electronically recorded? Yes No If yes, date requested:
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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 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): 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: N Name of person filing out mediation section of docketing statement: N
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:
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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?
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?
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 affidavit of Indigency and attached a file-stamped copy of that affidavit, 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 Affidavit of Indigency 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 an affidavit 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).
*7 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)
Clectronic Signature: (Optional) State Bar No.:
Certainty (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: | | | State | Zip +4: | | Telephone: | ext. | | Fax: | | | Email: | |
If Attorney, Representing Party's Name:
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