CIVIL CASE INFORMATION STATEMENT CIVIL CASES
(Other than Domestic Relations)
In the Circuit Court,
County, West Virginia
I. CASE STYLE: Plaintiff(s) Case # Judge:
vs. Defendant(s) Days to Answer Type of Service
Street City, State, Zip
Street City, State, Zip
Street City, State, Zip
Street City, State, Zip Original and
SCA-C100.02 / 1 of 2
copies of complaint enclosed/attached.
PLAINTIFF: DEFENDANT:
CASE NUMBER:
II. TYPE OF CASE:
G G
General Civil Mass Litigation (As defined in T.C.R. Rule XIX (c)
G G G
Adoption Administrative Agency Appeal Civil Appeal from Magistrate Court Miscellaneous Civil Petition Mental Hygiene Guardianship Medical Malpractice
G G G G G G G G G
Asbestos Carpal Tunnel Syndrome Diet Drugs Environmental Industrial Hearing Loss Silicone Implants Other:
G G G G
Habeas Corpus/Other Extraordinary Writ Other:
III.
JURY DEMAND: G Yes G No CASE WILL BE READY FOR TRIAL BY (MONTH/YEAR): _______/_______
IV.
DO YOU OR ANY OF YOUR CLIENTS OR WITNESSES IN THIS CASE REQUIRE SPECIAL ACCOMMODATIONS DUE TO A DISABILITY? G YES G NO IF YES, PLEASE SPECIFY:
G Wheelchair accessible hearing room and other facilities G Interpreter or other auxiliary aid for the hearing impaired G Reader or other auxiliary aid for the visually impaired G Spokesperson or other auxiliary aid for the speech impaired G Other:_______________________________________________________________________
Attorney Name: Firm: Address: Telephone: Dated:
Representing:
G Plaintiff
G Defendant
G Cross-Complainant G Cross-Defendant
Signature
G Proceeding Without an Attorney
SCA-C100.02 / 2 of 2