Civil Appeals Statement Form - United States Court Of Appeals Page 2

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                    11th Circuit Docket Number:    ____________________________     
 
 
 
Based on your present knowledge: 
 
Does this appeal involve a question of First Impression?      9 Yes      9 No 
(1) 
          What is the issue you claim is one of First Impression? 
 
Will the determination of this appeal turn on the interpretation or application of a particular case or statute?        9 Yes      9 No 
(2) 
           
          If Yes, provide 
          (a)  Case Name/Statute 
          (b)  Citation 
          (c)  Docket Number if unreported 
 
(3) 
Is there any case now pending or about to be brought before this court or any other court or administrative agency that 
          (a)  Arises from substantially the same case or controversy as this appeal?      9 Yes      9 No 
          (b)  Involves an issue that is substantially the same, similar, or related to an issue in this appeal?      9 Yes      9 No 
 
          If Yes, provide 
          (a)  Case Name 
 
          (b)  Citation 
          (c)  Docket Number if unreported 
          (d)  Court or Agency 
 
(4) 
Will this appeal involve a conflict of law   
          (a)  Within the Eleventh Circuit?      9 Yes      9 No 
          (b)  Among circuits?      9 Yes      9 No 
 
          If Yes, explain briefly: 
 
 
 
 
 
(5)      Issues proposed to be raised on appeal, including jurisdictional challenges:   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
I CERTIFY THAT I SERVED THIS CIVIL APPEAL STATEMENT ON THE CLERK OF THE U.S. COURT OF APPEALS FOR THE ELEVENTH CIRCUIT AND   
 
SERVED A COPY ON EACH PARTY OR THEIR COUNSEL OF RECORD, THIS ____________ DAY OF ___________________________, ____________. 
 
 
 
_______________________________________________________       
_______________________________________________________ 
                                NAME OF COUNSEL (Print)                                                                                  SIGNATURE OF COUNSEL                                                             
 
Please ATTACH portion of district court, tax court, or agency record described in 11th Cir. R. 33‐1(b):    (a) judgments and orders appealed 
from or sought to be reviewed; (b) any supporting opinion, findings of fact, and conclusions of law filed by the court or the agency, board, 
commission, or officer; (c) any report and recommendation adopted by an order; (d) findings and conclusions of an administrative law judge 
when appealing a court order reviewing an agency determination; (e) any agency docket sheet or record index. 

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