District of Columbia Court of Appeals Washington, D. C. 20001

Open to All Trusted by All Justice for All

Civil Appeals Screening Statement

App. No. __________________

Superior Ct. No. ____________

1. Full caption:

2. Case type and a brief description of the facts that caused the initial dispute, including anyinjuries on which the claim for compensation is based, if applicable:

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_______________________________________________________________________

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3. Nature of disposition below: Attach a copy of the order(s) on appeal to this form.

Bench trial DismissalJury verdict Forum non conveniens Summary judgment Lack of jurisdiction Grant/denial of injunction Failure to state a claim Default judgment Failure to prosecute Other (specify) ________________________________________________________

4. State concisely the principal issue(s) in this appeal and the standard of review governing each:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

5. Does this appeal present any new question of law? yes noIf yes, what is that question:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Open to All Trusted by All Justice for All

6. Nature of relief sought below:

Damages: Amount sought $ _________ Amount received $ _________

Injunctive relief: Temporary Preliminary Permanent Granted Denied

Declaratory relief: Granted Denied

Attorney fees: Amount sought $ ________ Amount received $ ________

7. Are there any factors that may influence the suitability of mediation?

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______________________________________________________________________

______________________________________________________________________

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I certify that the above information is accurate to the best of my knowledge.

_____________________________________Signature

Name _______________________________

Bar No. ______________________________

Address ______________________________

______________________________

Telephone No. _________________________

CERTIFICATE OF SERVICE

I hereby certify that a copy of this screening statement was served by hand/mailed, firstclass postage prepaid, this _____________ day of _____________, 20___, on the following:

Signature: ________________________________

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App No: undefined: Superior Ct No: injuries on which the claim for compensation is based, if applicable 1: injuries on which the claim for compensation is based, if applicable 2: injuries on which the claim for compensation is based, if applicable 3: Failure to prosecute: 4 State concisely the principal issues in this appeal and the standard of review governing each 1: 4 State concisely the principal issues in this appeal and the standard of review governing each 2: 4 State concisely the principal issues in this appeal and the standard of review governing each 3: If yes, what is that question 1: If yes, what is that question 2: If yes, what is that question 3: Damages: Amount sought: Amount received: Attorney fees: Amount sought: Amount received_2: 7 Are there any factors that may influence the suitability of mediation 1: 7 Are there any factors that may influence the suitability of mediation 2: 7 Are there any factors that may influence the suitability of mediation 3: 7 Are there any factors that may influence the suitability of mediation 4: Name: Bar No: Address 1: Address 2: Telephone No: class postage prepaid, this: day of: Bench Trial: Jury Verdict: Check Box35: Summary Judgement: Lack of Jurisdiction: Grant/denial of injunction: Check Box33: Default judgement: Check Box34: Nature of relief sought? - Check here for Damages: Nature of relief sought? - Check here for Injuctive Relief: Injunctive Relief - Check here for Temporary: Injunctive Relief - Check here for Preliminary: Injunctive Relief - Check here for Permanant: Injunctive relief - Granted: Injunctive relief - Denied: Declaratory Relief:

Declaratory Relief - Check here for Granted: Declaratory Relief -Check here for Denied: Attorney fees: Year: