Fill and Sign the West Virginia Civil Form

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. Days to Defendant(s) Answer Type of Service                   Street                   City, State, Zip             Street                   City, State, Zip             Street                   City, State, Zip             Street                   City, State, Zip Original and       copies of complaint enclosed/attached. SCA-C100.02 / 1 of 2 PLAINTIFF: CASE NUMBER: DEFENDANT: II. TYPE OF CASE: General Civil Adoption Mass Litigation Administrative Agency Appeal (As defined in T.C.R. Rule XIX (c) Civil Appeal from Magistrate Court Asbestos Carpal Tunnel Syndrome Miscellaneous Civil Petition Diet Drugs Environmental Mental Hygiene Industrial Hearing Loss Silicone Implants Guardianship Other:       Medical Malpractice Habeas Corpus/Other Extraordinary Writ Other:       III. JURY DEMAND: Yes 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? YES NO IF YES, PLEASE SPECIFY: Wheelchair accessible hearing room and other facilities Interpreter or other auxiliary aid for the hearing impaired Reader or other auxiliary aid for the visually impaired Spokesperson or other auxiliary aid for the speech impaired Other:       Attorney Name:       Representing: Firm:       Plaintiff Defendant Address:       Cross-Complainant Cross-Defendant Telephone:       Dated:             Signature Proceeding Without an Attorney SCA-C100.02 / 2 of 2