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County Where Claim for Relief Arose: Yes No Basis of Jurisdiction: 1. U.S. Government Plaintiff 2. U.S. Government Defendant 3. Federal Question (U.S. not a party) 4. Diversity of Citizenship Origin: 1. Original Proceeding 2. Removed From State Court 3. Remanded From USCA 4. Reinstated or Reopened Case 5. Transfer-in from Other District 6. Multidistrict Litigation - Transfer 8. Multidistrict Litigation - Direct File County: Case Number: District: Alabama MiddleAlabama NorthernAlabama SouthernAlaskaArizonaArkansas EasternArkansas WesternCalifornia CentralCalifornia EasternCalifornia NorthernCalifornia SouthernColoradoConnecticutDelawareDistrict of ColumbiaFlorida MiddleFlorida NorthernFlorida SouthernGeorgia MiddleGeorgia NorthernGeorgia SouthernGuamHawaiiIdahoIllinois CentralIllinois NorthernIllinois SouthernIndiana NorthernIndiana SouthernIowa NorthernIowa SouthernKansasKentucky EasternKentucky WesternLouisiana EasternLouisiana MiddleLouisiana WesternMaineMarylandMassachusettsMichigan EasternMichigan WesternMinnesotaMississippi NorthernMississippi SouthernMissouri EasternMissouri WesternMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew York EasternNew York NorthernNew York SouthernNew York WesternNorth Carolina EasternNorth Carolina MiddleNorth Carolina WesternNorth DakotaNorthern Mariana IslandsOhio NorthernOhio SouthernOklahoma EasternOklahoma NorthernOklahoma WesternOregonPennsylvania EasternPennsylvania MiddlePennsylvania WesternPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennessee EasternTennessee MiddleTennessee WesternTexas EasternTexas NorthernTexas SouthernTexas WesternUtahVermontVirgin IslandsVirginia EasternVirginia WesternWashington EasternWashington WesternWest Virginia NorthernWest Virginia SouthernWisconsin EasternWisconsin WesternWyoming Case Number: Class Action: If an original proceeding, is the case being filed as a Class Action Under FRCP23?

If removed from state court, was the case filed as a Class Action under State statute or rule?

Not filed as a Class Action Cause of Action:

(Cite the U.S. Statute under which you are filing and write a brief statement of cause.

Do not cite jurisdictional statutes unless diversity.) Related Cases: is not a refiling of a previously dismissed action.

is related to case number , currently pending before Judge .

is a refiling of case number , previously dismissed by Judge . III. Nature of Suit Nature of Suit Code Descriptions Micellaneous Case999 Micellaneous Case - Use ONLY when filing a misc (MC) caseAdministrative Agency899 Administrative Procedures Act/Review or Appeal of Agency DecisionAgricultural - Title 7 U.S.C.891 Agricultural Actions (e.g., PACA)899 Administrative Procedures Act/Review or Appeal of Agency DecisionArbitration - Title 9 U.S.C.896 Confirm or Modify Arbitration AwardBanking and Consumer Credit140 Negotiable Instruments371 Truth in Lending Act430 Banks and Banking480 Fair Credit Reporting Act or Fair Debt Collection Practices ActBankruptcy422 Appeal to District Court423 Withdrawal of ReferenceBusiness and Commercial160 Shareholder Derivative Actions410 Antitrust

450 Interstate Commerce (e.g., Carmack Amendment)850 Securities, Commodities, ExchangesCivil Rights - Non Prisoner441 Voting Rights442 Employment443 Housing and Accommodations445 Americans With Disabilities Act - Employment446 Americans with Disabilities Act - All Other448 Education (e.g., IDEA)440 All Other Civil Rights Contracts110 Insurance Contracts120 Marine Contracts130 Miller Act195 Warranties196 Franchise Agreements190 All Other Contract ActionsEnvironmental893 Environmental Matters899 Administrative Procedures Act/Review or Appeal of Agency DecisionForfeiture and Penalty625 Drug-Related Seizure of Property (21 U.S.C. 881)690 All Other Forfeiture and Penalty ActionsFraud and False Claims370 Fraud Actions

375 False Claims Act (31 U.S.C. 3729)376 Qui Tam (31 U.S.C. 3729)Freedom of Information Act

895 Freedom of Information ActImmigration462 Naturalization Applications463 Habeas Corpus - Alien Detainee465 Other Immigration ActionsIntellectual Property820 Copyright830 Patent835 Patent - Abbreviated New Drug Applications (ANDA)840 TrademarkLabor710 Fair Labor Standards Act720 Labor-Management Relations/Reporting740 Railway Labor751 Family and Medical Leave Act791 ERISA790 Other Labor Actions Prisoner Petitions510 Motion to Vacate Sentence530 Habeas Corpus535 Habeas Corpus - Death Penalty540 Prisoner Petition for Writ of Mandamus550 Prisoner Civil Rights 555 Prison Conditions 560 Civil Detainee - Conditions of ConfinementReal Property210 Land Condemnation220 Foreclosure230 Rent, Lease, and Ejectment240 Torts to Land/Real Property Damage245 Real Property Damage Product Liability290 Other Real Property ActionsRecovery of Overpayment and Enforcement of Judgments150 Other Recovery Actions/Enforcement of Judgements151 Overpayment of Medicare Benefits152 Defaulted Student Loans153 Overpayment of Veterans' BenefitsRICO470 Civil RICO ActionsSocial Security Appeals861 Medicare - HIA (1395ff)862 Black Lung863 DWIC/DIWW (405(g))864 SSID Title XVI865 RSI (405(g)) FOR SOCIAL SECURITY APPEALS ONLY

If this case seeks review of

an application that was previously

awarded by this court, please enter

the case number:

Tax Suits870 Tax Suits (U.S. a party)871 Third Party Tax SuitsTortsPersonal Injury310 Airplane Personal Injury320 Assault, Libel, Slander330 FELA (45 U.S.C. 51)340 Jones Act/Marine Personal Injury350 Motor Vehicle Personal Injury362 Medical Malpractice360 Other Personal Injury ActionsPersonal Injury Product Liability245 Real Property Damage Product Liability315 Airplane Product Liability345 Marine Product Liability355 Motor Vehicle Product Liability367 Health Care/Pharmaceutical Product Liability368 Asbestos Product Liability365 Other Personal Injury Product LiabilityProperty Damage240 Torts to Land/Real Property Damage245 Real Property Damage Product Liability380 Personal Property Damage385 Personal Property Damage Product LiabilityOther Statutes400 State Reapportionment485 Telephone Consumer Protection Act490 Illegally Accessing Satellite/Cable TV Signals880 Defend Trade Secrets Act of 2016950 Constitutionality of State Statutes890 Other Statutory Actions

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Free Download Fax Cover Sheet Form

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The Local Intellectual and Developmental Disability Authority (LIDDA) service coordinator for the TxHmL program and the program provider for the HCS program complete all information on the IPC Cover Sheet and submit to HHSC with documentation justifying the services.

The JS 44 civil cover sheet and the information contained herein neither replaces nor supplements the filings and service of pleading or other papers as required by law, except as provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. Consequently, a civil cover sheet is submitted to the Clerk of Court for each civil complaint filed.

In order to fulfill the requirements needed on a cover memo for proper return of your request, the Division of Corporations has provided an Acrobat fillable Form for use by clients submitting a request. Please only submit one Cover Memo. You may use either your company letterhead with the information that is in the cover memo below or the cover memo itself but please only send one cover memo.

When submitting your memo, you must complete your name and address and supply us with a phone number, fax number or e-mail address so that we may contact you if there is a problem with your submission. You must complete all information on the form including file number or reservation number. If you are submitting a new entity filing, you will not be assigned a filing number until after the filing has been completed therefore it is not necessary to complete this information. If you have submitted a request to our office in the past, you have been assigned an account number. If you are unsure of your account number, please leave it blank as it is not necessary to complete your request. Please DO NOT STAPLE your request and be sure that you accompany your request with the appropriate fees that are required.

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The "Previous Grants.gov Tracking ID" field is required if you checked the "Changed/Corrected Application" box in "Field 1. Type of Submission." A Tracking ID number is of the form, for example, GRANT12345678.

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