Mississippi Civil Case Cover Sheet Form
If you intend to apply for any civil matter to a court in the State of Mississippi, the Mississippi Civil Case Cover Sheet Form has to be completed and submitted.
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Individual
_
__
MS Testate Estate
Other
____________________ _ Other __________________ _ Other ____________________ _ Other _________________ _
COVER SHEE T Court Identification Docket #
Case Year Docket Number
Civil Case Filing Form
(To be completed by Attorney/Party County #
Judicial
District Court ID
(CH, CI, CO)
Prior to Filing
of Pleading) Local Docket ID
Mississippi Supreme Court Form AOC/01Date
Month Year
Administrative Office of Courts (Rev This area to be completed by clerk
2009) Case Number if filed prior to 1/1/94
In the Court of County― Judicial District
Origin of Suit (Place an "X" in one box only ) Initial Filin g Reinstated Foreign Judgment Enrolled Transfer from Other cour t Othe r
Remanded ReopenedJoining Suit/Action Appeal
Plaintiff ‐ Party(ies) Initially Bringing Suit Should Be Entered First ‐ Enter Additional Plaintiffs on Separate Form
Individual
Last Name First Name Maiden Name, if
M.I.
applicabl e Jr/Sr/III/IV
____ Check ( x ) if Individual Plainitiff is acting in capacity as Executor(trix) or Administrator(trix) of an Estate, and enter style:
Estate o f
____ Check ( x ) if Individual Planitiff is acting in capacity as Business Owner/Operator (d/b/a) or State Agency, and enter entit y D/B/A or Agenc y
Business
Enter legal name of business, corporation, partnership, agency ‐ If Corporation, indicate the state where incorporated
____ Check ( x ) if Business Planitiff is filing suit in the name of an entity other than the above, and enter below:
D/B/A
Address of Plaintiff
Attorney (Name & Address) MS Bar No.
____ Check ( x ) if Individual Filing Initial Pleading is NOT an attorney
Signature of Individual Filing:
Defendant ‐ Name of Defendant ‐ Enter Additional Defendants on Separate Form
Individual
Last Name First Name Maiden Name, if M.I.
applicabl e Jr/Sr/III/IV
____ Check ( x ) if Individual Defendant is acting in capacity as Executor(trix) or Administrator(trix) of an Estate, and enter style:
Estate o f
____ Check ( x ) if Individual Defendant is acting in capacity as Business Owner/Operator (d/b/a) or State Agency, and enter entity:
D/B/A or Agenc y
Business
Enter legal name of business, corporation, partnership, agency ‐ If Corporation, indicate the state where incorporated
____ Check ( x ) if Business Defendant is acting in the name of an entity other than the above, and enter below:
D/B/A
Attorney (Name & Address) ‐ If Known MS Bar No.
Damages Sought: Compensatory $ Punitive $Check ( x ) if child support is contemplated as an issue in this suit.*
*If checked, please submit completed Child Support Information Sheet with this Cover She et
Nature of Suit (Place an "X" in one box only ) Children/Minors ‐ Non‐Domestic Real Property Domestic Relation s Business/Commercial Adoption ‐ Contested Adverse Possession
Child Custody/Visitatio n Accounting (Business ) Adoption ‐ Uncontested Ejectment
Child Suppor t Business Dissolutio n Consent to Abortion Mino r Eminent Domain
Contempt Debt Collection
Removal of Minorit y Eviction
Divorce:Faul t Employment Other ____________________ _ Judicial Foreclosur e
Divorce: Irreconcilable Diff . Foreign Judgment Civil Rights Lien Assertion
Domestic Abuse
Garnishmen t Elections Partition
Emancipation Replevin ExpungementTax Sale: Confirm/Cancel
Modification Other
__________________ _ Habeas Corpus Title Boundary or Easemen t
Paternit y Probate Post Conviction Relief/Prisone r Other _________________ _
Property Division Accounting (Probate) Other ____________________ _ Torts
Separate Maintenanc e Birth Certificate Correctio n Contract Bad Faith
Termination of Parental Right s Commitment Breach of Contrac t Fraud
UIFSA (eff 7/1/97; formerly URESA)
Conservatorshi p Installment Contrac t Loss of Consortium
Other ____________________ GuardianshipInsurance Malpractice ‐ Legal
Appeals Heirship
Specific Performanc e Malpractice ‐ Medica l
Administrative Agenc y Intestate Estat e Other ___________________ Mass Tort
County Cour t Minor's Settlemen t Statutes/Rule s Negligence ‐ General
Hardship Petition (Driver License ) Muniment of Titl e Bond Validation Negligence ‐ Motor Vehicl e
Justice Cour t Name Change Civil Forfeitur e Product Liabilit y
MS De pt Em ployment Securit y Dept Employment Security Testate Estate Declarator y Jud gmen t Declaratory Judgment Subro gation Subrogation
Worker's Compensation Will Contes t Injunction or Restraining Orde r Wrongful Death
IN THE COURT OF COUNTY , MISSISSIPPI
JUDICIAL DISTRICT , CITY OF
Docket No. - Docket No. If Filed
File Yr Chronological No. \
Clerk’s Local ID Prior to 1/1/94
PLAINTIFFS IN REFERENCED CAUSE - Page 1 of Plaintiffs Pages
IN ADDITION TO PLAINTIFF SHOWN ON CIVIL CASE FILING FORM COVER SHEET
Plaintiff #2:
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Plaintiff is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T) if Individual Plaintiff is acting in capacity as Business Owner/Opera\
tor (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Plaintiff is filing suit in the name of an entity other t\
han the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS PLAINTIFF : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Plaintiff #3:
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Plaintiff is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T) if Individual Plaintiff is acting in capacity as Business Owner/Opera\
tor (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Plaintiff is filing suit in the name of an entity other t\
han the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS PLAINTIFF : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Plaintiff #4:
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Plaintiff is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T) if Individual Plaintiff is acting in capacity as Business Owner/Opera\
tor (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Plaintiff is filing suit in the name of an entity other t\
han the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS PLAINTIFF : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
IN THE COURT OF COUNTY , MISSISSIPPI
JUDICIAL DISTRICT , CITY OF
Docket No. - Docket No. If Filed
File Yr Chronological No. \
Clerk’s Local ID Prior to 1/1/94
PLAINTIFFS IN REFERENCED CAUSE - Page of Plaintiffs Pages
IN ADDITION TO PLAINTIFF SHOWN ON CIVIL CASE FILING FORM COVER SHEET
Plaintiff # :
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Plaintiff is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T) if Individual Plaintiff is acting in capacity as Business Owner/Opera\
tor (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Plaintiff is filing suit in the name of an entity other t\
han the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS PLAINTIFF : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Plaintiff # :
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Plaintiff is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T) if Individual Plaintiff is acting in capacity as Business Owner/Opera\
tor (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Plaintiff is filing suit in the name of an entity other t\
han the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS PLAINTIFF : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Plaintiff # :
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Plaintiff is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T) if Individual Plaintiff is acting in capacity as Business Owner/Opera\
tor (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Plaintiff is filing suit in the name of an entity other t\
han the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS PLAINTIFF : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
IN THE COURT OF COUNTY , MISSISSIPPI
JUDICIAL DISTRICT , CITY OF
Docket No. - Docket No. If Filed
File Yr Chronological No. \
Clerk’s Local ID Prior to 1/1/94
DEFENDANTS IN REFERENCED CAUSE - Page 1 of Defendants Pages
IN ADDITION TO DEFENDANT SHOWN ON CIVIL CASE FILING FORM COVER SHEET
Defendant #2:
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Defendant is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T)
if Individual Defendant is acting in capacity as Business Owner/Operator (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Defendant is being sued in the name of an entity other than the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS DEFENDANT : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Defendant #3:
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Defendant is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T)
if Individual Defendant is acting in capacity as Business Owner/Operator (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Defendant is being sued in the name of an entity other than the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS DEFENDANT : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Defendant #4:
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Defendant is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T)
if Individual Defendant is acting in capacity as Business Owner/Operator (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Defendant is being sued in the name of an entity other than the above, and enter below:
D/B/A
A
TTORNEY FOR THIS DEFENDANT : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
IN THE COURT OF COUNTY , MISSISSIPPI
JUDICIAL DISTRICT , CITY OF
Docket No. - Docket No. If Filed
File Yr Chronological No. \
Clerk’s Local ID Prior to 1/1/94
DEFENDANTS IN REFERENCED CAUSE - Page of Defendants Pages
IN ADDITION TO DEFENDANT SHOWN ON CIVIL CASE FILING FORM COVER SHEET
Defendant # :
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Defendant is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T)
if Individual Defendant is acting in capacity as Business Owner/Operator (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Defendant is being sued in the name of an entity other than the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS DEFENDANT : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Defendant # :
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Defendant is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T)
if Individual Defendant is acting in capacity as Business Owner/Operator (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Defendant is being sued in the name of an entity other than the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS DEFENDANT : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
Defendant # :
Individual : \
( ) \
Last Name \
First Name \
Maiden Name, if Applicable Middle Init. \
Jr/Sr/III/IV
___Check ( T) if Individual Defendant is acting in capacity as Executor(trix) or \
Administrator(trix) of an Estate, and enter style:
Estate of
___Check ( T)
if Individual Defendant is acting in capacity as Business Owner/Operator (D/B/A) or State Agency, and enter that name below:
D/B/A
Business
Enter legal name of business\
, corporation, partnership, agency - If Corporation, indicate state wher\
e incorporated
Check (T) if Business Defendant is being sued in the name of an entity other than the name above, and enter below:
D/B/A
A
TTORNEY FOR THIS DEFENDANT : Bar # or Name: Pro Hac Vice (T ) Not an Attorney( T)
CHILD SUPPORT INFORMATION SHEETPlease include all information known
I
N THE COURT OF C OUNTY , MISSISSIPPI
JUDICIAL DISTRICT , CITY OF
Docket No. - Docket No. If Filed
File Yr Chronological No. \
Clerk’s Local ID Prior to 1/1/94
Father:
Last First M/I Jr/Sr etc. Date of Birth \
Social Security #
Address: ( )
Phone # Drivers License #
Employer Name and Address: ( )
Employer Phone #
Mother:
Last First M/I Jr/Sr etc. Date of Birth \
Social Security #
Address: ( )
Phone # Drivers License #
Employer Name and Address: ( )
Employer Phone #
Child:
Last First M/I Jr/Sr etc. Date of Birth \
Social Security #
Address: ( )
Phone #
Child :
Last First M/I Jr/Sr etc. Date of Birth \
Social Security #
Address: ( )
Phone #
Child :
Last First M/I Jr/Sr etc. Date of Birth \
Social Security #
Address: ( )
Phone #
Child :
Last First M/I Jr/Sr etc. Date of Birth \
Social Security #
Address: ( )
Phone #
FOR
ADDITIONAL CHILDREN, PLEASE ATTACH ADDITIONAL FORMS
MANDATED PURSUANT TO :
Federal Social Security Act Title IV-D, Information will be sent to the
§§ 454(26)(A) and 454A(e)(4); ADMINISTRATIVE OFFICE OF COURTS AND
Miss. Code Ann. §43-19-31(l)(iii) (Supp. 1999) MDHS CHILD SUPPORT ENFORCEMENT DIVISION
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