S E C T I O N A

SECTION

S E C T I O N B

Supreme Court of Pennsylvania Court of Common Pleas Civil Cover Sheet

Adams County

1722

For Prothonotary Use Only: TIME STAMP

Docket No:

The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service of pleadings or other papers as required by law or rules of court.

Commencement of Action: ☐ Complaint ☐ Writ of Summons ☐ Petition ☐ Transfer from Another Jurisdiction ☐ Declaration of Taking

Lead Plaintiff's Name: Are money damages requested? ☐ Yes ☐ No Lead Defendant's Name: Adams County Board of Assessment Appeals

Dollar Amount Requested: (check one) ☐ within arbitration limits ☐ outside arbitration limits

Is this a Class Action Suit? ☐ Yes ☒ No Is this an MDJ Appeal? ☐ Yes ☐ No

Name of Plaintiff/Appellant's Attorney: ________________ ☐ Check here if you have no attorney (are a Self-Represented [Pro Se] Litigant)

Nature of the Case: Place an “X” to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that you consider most important.

TORT (do not include Mass Tort) ☐ Intentional ☐ Malicious Prosecution ☐ Motor Vehicle ☐ Nuisance ☐ Premises Liability ☐ Product Liability (does not include mass tort) ☐ Slander/Libel/ Defamation ☐ Other: ________________ CONTRACT (do not include Judgments) ☐ Buyer Plaintiff ☐ Debt Collection: Credit Card ☐ Debt Collection: Other ______________ ☐ Employment Dispute: Discrimination ☐ Employment Dispute: Other ______________ ☐ Other: ________________ CIVIL APPEALS Administrative Agencies ☒ Board of Assessment ☐ Board of Elections ☐ Dept. of Transportation ☐ Statutory Appeal: Other ______________ ☐ Zoning Board ☐ Other: ________________

MASS TORT ☐ Asbestos ☐ Tobacco ☐ Toxic Tort - DES ☐ Toxic Tort - Implant ☐ Toxic Waste ☐ Other: ________________ REAL PROPERTY ☐ Ejectment MISCELLANEOUS ☐ Common Law/Statutory Arbitration

REAL PROPERTY ☐ Ejectment ☐ Eminent Domain/Condemnation ☐ Ground Rent ☐ Landlord/Tenant Dispute ☐ Mortgage Foreclosure: Residential ☐ Mortgage Foreclosure: Commercial ☐ Partition ☐ Quiet Title ☐ Other: MISCELLANEOUS ☐ Common Law/Statutory Arbitration ☐ Declaratory Judgment ☐ Mandamus ☐ Non-Domestic Relations Restraining Order ☐ Quo Warranto ☐ Replevin ☐ Other:

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□ Other:

PROFESSIONAL LIABILITY

☐ Dental

☐ Legal

☐ Medical

☐ Other Professional:

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Updated 1/1/2011