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STATE OF FLORIDA

[dca] DISTRICT COURT OF APPEALS

[plfName]	)
Appellant	)
)	Case No.:	[caseNo]
V	)	LT No. (FCHR):	[caseNoF]
)
[defName]	)
)

APPELLANT’S DOCKETING STATEMENT

Appellant, [plfName], on this [D]th day of [MMM] [YYYY], respectfully files his Docketing Statement. Appellant is moving Pro Se, and pursuant to Administrative Order 19-1 (Florida’s [dca] DCA).

IN THE DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA

[dca] DISTRICT

DOCKETING STATEMENT

AND NOTICE OF APPEARANCE OF COUNSEL

This Court requires the following information in order to facilitate disposition of the case.

APPELLANT/PETITIONER: If this case involves an original writ, is an appeal of a non-final order or is a case involving child custody, this docketing statement must be completed and returned within five days. In all other cases, the appellant must file the docketing statement within 20 days from the date of the acknowledgment of the notice of appeal.

APPELLEE/RESPONDENT: is not required to file a docketing statement unless there are amendments, corrections or additions to the docketing statement filed by the appellant/petitioner. Appellee/respondent is only required to file a notice of appearance if counsel’s name does not already appear on the certificate of service. Appellee’s/respondent’s docketing statement, if necessary, is due within 5 days from service of the appellant’s/petitioner’s docketing statement.

PLEASE PROVIDE THE FOLLOWING INFORMATION

DOCKETING STATEMENT OF: (CHECK ONE)	APPELLANT/PETITIONER	√
APPELLE/RESPONDENT

1.	STYLE OF CASE	DCA CASE NO	LOWER TRIBUNAL CASE NO
[plfName] v [defName]	[caseNo]	[caseNoF]

2a.	NOTICE OF APPEARANCE OF COUNSEL FOR APPELLANT (If party is not represented by counsel, party should so indicate and provide accurate mailing address and phone number).
Name	[attName]	Bar Number	[barNo]
Address	[addy]	Email	[eml]
Attorney For	Phone Number	[phn]	Fax	[fax]

2b.	RESPONDENT’S TRIAL COUNSEL AND/OR APPELLATE COUNSEL (IF KNOWN)
Name	[attNameRsp]	Bar Number	[barNoRsp]
Address	[addyRsp]	Email	[emlRsp]
Attorney For	Phone Number	[phnRsp]	Fax	[fax]

3.	INTERESTED PERSONS: List names of all persons or entities having an interest in this matter. Please clarify whether these person or entities are parties, lawyers or otherwise, and as to parties, designate whether appellant or appellee:
Name
Affiliation
Lawyer
Name
Affiliation
Lawyer
Name
Affiliation
Lawyer

4.	JUDGES BELOW: List the name of all judges, deputy commissioners and hearing officers/examiners who were involved in this action below. Specify the judge who entered the order appealed.
Name	Order(s) Being Appealed?
Name	Order(s) Being Appealed?

5.	JURISDICTION: State the basis for this court’s jurisdiction, including the following:
the appellate rule providing jurisdiction claimed:
the date of filing in the lower tribunal of the order appealed
if this is an appeal from a final order
the date of the return of verdict in a jury action
the service date of any Fla. R. Civ. P. 1.530 motion
and the date of the order deciding such motion

6.	PENDING MATTERS IN LOWER TRIBUNAL: Are there any matters, including counts of claims or counterclaims, still pending in the lower tribunal? If yes, please explain exactly what remains pending.

7.	CURRENT AND PRIOR PROCEEDINGS IN THIS COURT:
List by style and case number of this court, all cases which are or have been pending before this court involving issues arising from the same lower tribunal case and the current status of same:
Criminal Appeals: List by style and case number of this court all co-defendants currently or previously on appeal to this court.
Similar Issues: List by style and case number of this court, all cases which are or have been pending before this court which are related to this action or which involve an issue which will be similar or determinative to the issue in this case on appeal.

8.	Court Transcript:
Do you intend to order any portion of the transcript for the appeal?
If yes, have all arrangements been made for its preparation?
If yes, date ordered?
If no, why not?
Estimated date of completion:
Estimated number of pages:
Name and address of court reporter(s):

9.	CUSTODY STATUS IN CRIMINAL APPEALS
Is the appellant in custody and serving a sentence imposed as a result of a conviction which is the subject of this appeal?
If so, state the length of the sentence imposed:

10.	ISSUES
If this case involves the determination of the constitutionality of a statute, cite the statute involved.
Please state in short form the anticipated issues raised. For example, on criminal issues: denial of motion for judgment of acquittal, denial of motion to suppress evidence, error in sentence; on civil issues, award of alimony, error in valuation of assets for equitable distribution, error in determining contract damages; error in admission of hearsay at trial

11.	TYPE OF CASE: PLACE A CHECK BY THE MOST APPROPRIATE TYPE OF CASE
Civil
Domestic Relations – divorce, child custody, paternity or support
Child dependency
Adoption/Termination of Parental Rights
Professional Malpractice
Products Liability
Negligence
Contract or indebtedness
Condominium – rules violations, developer suits
Foreclosure – mortgage, lien
Inmate Appeal – gain time, rule challenges, disciplinary action
Attorney’s Fees
All others – specify

Criminal
Direct Appeal – judgment and sentence
Direct Appeal – sentence only
Direct Appeal – juvenile
Collateral Attack – (Rule 3.850 or habeas corpus) – judgment and sentence
Collateral Attack – (Rule 3.800, Rule 3.850 or habeas corpus) – sentence only
Collateral attack – juvenile
Appeal by the State
All others – specify

Civil
Department of Professional Regulation
Unemployment Appeals Commission
Rule Challenge – specify agency
All others – specify

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that on this [D]th day of [MMM] [YYYY], I electronically filed the foregoing with the Clerk of Courts by using the Florida Courts E-filing Portal which will send a notice of electronic filing to the attached service list.

/s/ [plfName]

[plfName], Appellant

[plfAddy]

P: [plfPhn]

E: [plfEml]

W: TextBookDiscrimination.com

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How-To Guide: (interactive)

TextBookDiscrimination.com/Guides/DocketingStatement.html

SERVICE LIST

[clrkNm], Agency Clerk [clrkEml]@fchr.myflorida.com Florida Commission on Human Relations Room 110 4075 Esplanade Way Tallahassee, Florida 32399-7020 (agency)

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