Form 6

IN THE ________________________________________

(Court or Agency From Which Appeal is Taken)

CIVIL APPEAL DOCKETING STATEMENT

(For Use By The Appellate Mediation Program)

PLEASE ATTACH ADDITIONAL PAGES IF NECESSARY.	THIS SPACE FOR OFFICE USE ONLY
TITLE	Trial Court/Agency

Docket Number:
Is this a Cross-Appeal? _____ Yes _____ No
Has this matter previously been before the Hawai i Appellate Courts? _____ Yes _____ No

If yes, state when:

Case Name:

Docket Number:
CHECK AS MANY AS APPLICABLE
TRIAL COURT/AGENCY DISPOSITION
1.	STAGE OF PROCEEDINGS	2.	RELIEF
( )	Pre-Trial

( )	During Trial

( )	After Trial	( )	Damages:

Amount Sought:	$__________

Amount Granted: $__________

( )	Other (Specify)

DESCRIPTION OF NATURE OF ACTION AND RESULT IN THE TRIAL COURT OR AGENCY:

ANTICIPATED ISSUES PROPOSED TO BE RAISED ON APPEAL:

DOES THIS APPEAL INVOLVE ANY OF THE FOLLOWING:

_____	Likelihood of a motion to expedite the appeal.

_____	Likelihood of motions to stay appeal pending resolution of a related case. Identify case name, docket number, and court or agency:

_____	Other procedural complexities. If so, please identify them:

Appellants' Names:

COUNSEL FOR APPELLANTS:

NAME:

ADDRESS:

TELEPHONE ( )

EMAIL:	TRIAL COUNSEL FOR APPELLANT(S)

(If different from appeal counsel)

NAME:

ADDRESS:

TELEPHONE ( )

EMAIL:

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I CERTIFY THAT A COPY OF THIS CIVIL APPEAL DOCKETING STATEMENT WAS SERVED ON EACH PARTY/COUNSEL SHOWN ON THE ATTACHED SERVICE LIST.

_________________________________________________	________________________________

Signature	Date

REMEMBER TO ATTACH COPIES OF:

(1)	THE ORDER/JUDGMENT APPEALED FROM;

(2)	ANY WRITTEN OPINION OR FINDINGS OF FACT AND CONCLUSIONS OF LAW SUPPORTING THE ORDER/JUDGMENT; AND

(3)	PROOF OF SERVICE ON ALL OTHER PARTIES TO THE TRIAL COURT OR AGENCY PROCEEDINGS (WITH TELEPHONE NUMBERS AND EMAIL ADDRESSES)

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