IN THE CIRCUIT COURT OF COUNTY, WEST VIRGINIA CIVIL …

1 SCA-C-100: CIVIL case information Statement (Other than Domestic Relations) Revision Date: 12/2015IN THE CIRCUIT COURT OFCOUNTY, WEST VIRGINIACIVIL case information STATEMENT ( CIVIL Cases Other than Domestic Relations)I. case STYLE: case (s)Judge:vs. Defendant(s)NameStreet AddressCity, State, Zip Code Days to Answer Type of ServiceII. TYPE OF case :General CIVIL AdoptionMass Litigation [As defined in (a)] Administrative Agency appeal Asbestos CIVIL appeal from Magistrate COURT FELA Asbestos Miscellaneous CIVIL Petition Other: Mental HygieneHabeas Corpus/Other Extraordinary WritGuardianshipOther: Medical MalpracticeIII. JURY DEMAND:YesNo 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?YesNoIF YES, PLEASE SPECIFY:Wheelchair accessible hearing room and other facilites Reader or other auxiliary aid for the visually impaired Interpreter or other auxiliary aid for the deaf and hard of hearing Spokesperson or other auxiliary aid for the speech impaired Foreign language interpreter-specify language:Other:Attorney Name: Firm: Address: Telephone: Representing:PlaintiffDefendantCross-Def endantCross-Complainant3rd-Party Plaintiff3rd-Party DefendantProceeding Without an Attorney Dated: //Original andcopies of complaint :SCA-C-100: CIVIL case information Statement-Defendant(s) Continuation Page Revision Date: 12/2015 : case Number: CIVIL case information STATEMENT DEFENDANT(S) CONTINUATION PAGED efendant's NameStreet AddressCity, State, Zip CodeDays to Answer:Type of Service:Defendant's NameStreet AddressCity, State, Zip CodeDays to Answer.

2 Type of Service:Defendant's NameStreet AddressCity, State, Zip CodeDays to Answer:Type of Service:Defendant's NameStreet AddressCity, State, Zip CodeDays to Answer:Type of Service:Defendant's NameStreet AddressCity, State, Zip CodeDays to Answer:Type of Service:Defendant's NameStreet AddressCity, State, Zip CodeDays to Answer:Type of Service:Defendant's NameStreet AddressCity, State, Zip CodeDays to Answer:Type of Service.