Fill and Sign the Civil Appeals Screening Statement Form

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 any injuries on which the claim for compensation is based, if applicable: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. Nature of disposition below:Attach a copy of the order(s) on appeal to this form. Bench trial Dismissal Jury 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 no If 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? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 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, first class postage prepaid, this _____________ day of _____________, 20___, on the following: Signature: ________________________________