COMMONWEALTH OF VIRGINIA

GENERAL CIVIL CASE COVER SHEET

[// GUIDANCE: This template is modeled on Supreme Court of Virginia Form CC-1416 (Circuit Court) and adapted to be usable in any Virginia state trial court. Confirm with the clerk’s office whether a local variant or electronic filing portal supersedes this paper form.]

I. COURT & CASE IDENTIFICATION

1. Court Name: [___________]
   (e.g., “Circuit Court of Fairfax County”)

2. Civil Action No.: [___________] (Assigned by Clerk)

3. Case Style:
   Plaintiff(s): [Full legal name(s)]
   v.
   Defendant(s): [Full legal name(s)]

4. Filing Date (MM/DD/YYYY): [____ / ____ / ______]

5. Origin: ☐ Original Action ☐ Removal ☐ Transfer ☐ Reinstated/Reopened

II. CASE CATEGORY SELECTION

[// GUIDANCE: Select ONE primary category. Where multiple causes exist, choose the predominant basis for the filing; note secondaries under Section III.]

A. Contract:
 ☐ 0100 General Contract
 ☐ 0200 Confessed Judgment
 ☐ 0300 Warrant in Debt—Over $25,000
 ☐ 0400 Other Contract (specify): [___________]

B. Personal Injury / Wrongful Death:
 ☐ 1100 Motor Vehicle
 ☐ 1200 Medical Malpractice
 ☐ 1300 Product Liability
 ☐ 1400 Premises Liability
 ☐ 1500 Other Personal Injury (specify): [___________]
 ☐ 1600 Wrongful Death

C. Property Damage / Real Property:
 ☐ 2100 Conversion
 ☐ 2200 Trespass / Nuisance
 ☐ 2300 Ejectment
 ☐ 2400 Boundary / Easement
 ☐ 2500 Partition
 ☐ 2600 Other Real Property (specify): [___________]

D. Equity / Other Civil Relief:
 ☐ 3100 Declaratory Judgment
 ☐ 3200 Injunction
 ☐ 3300 Quiet Title
 ☐ 3400 Trust / Estate / Fiduciary
 ☐ 3500 Administrative Appeal
 ☐ 3600 Other Equity (specify): [___________]

E. Domestic Relations (NON-Juvenile):
 ☐ 4100 Divorce
 ☐ 4200 Annulment
 ☐ 4300 Support (non-IV-D)
 ☐ 4400 Other Domestic (specify): [___________]

F. Miscellaneous Statutory Actions:
 ☐ 5100 Habeas Corpus
 ☐ 5200 Mandamus / Prohibition
 ☐ 5300 Name Change
 ☐ 5400 Expungement
 ☐ 5500 Foreign Judgment Domestication
 ☐ 5600 Other Statutory (cite statute): [___________]

III. ADDITIONAL CAUSES OF ACTION (if any)

[List secondary or alternative claims with corresponding statutory citations if relied upon.]

IV. MONEY DAMAGES SOUGHT (if applicable)

1. Compensatory: $ [________]  2. Punitive: $ [________]
2. Other (identify): $ [________]
3. TOTAL Demand: $ [________]
   [// GUIDANCE: Under Va. Sup. Ct. R. 3:2(b), state the amount of money damages demanded, exclusive of interest and attorney’s fees, unless governed by medical malpractice cap or statutorily limited.]

V. DEMAND FOR JURY TRIAL

☐ Yes ☐ No
[// GUIDANCE: A written jury demand must also be filed pursuant to Va. Sup. Ct. R. 3:21.]

VI. ALTERNATIVE DISPUTE RESOLUTION

The parties: ☐ consent ☐ do not consent to referral to mediation or other ADR.

VII. SERVICE INFORMATION

1. Primary Defendant to be Served: [Name]
    Service Method Requested: ☐ Sheriff ☐ Private Process Server ☐ Secretary of the Commonwealth ☐ DMV ☐ Waiver of Service

2. Additional Defendants / Addresses / Methods:
   [Attach separate sheet if necessary]

3. Attorney for Plaintiff (or Pro Se litigant):
    Name: [___________] VSB No.: [_____]
    Address: [___________]
    Telephone: [___________] Email: [___________]

VIII. FEE SCHEDULE WORKSHEET

[// GUIDANCE: Clerk’s offices require prepayment of filing fees per Va. Code § 17.1-275 & Supreme Court Fee Schedule. Provide calculations for transparency and to expedite filing.]

Filing Type (circle one): Circuit Court / General District Court

1. Base Filing Fee: $ [_____]
2. Service Fees (per defendant): $ [_____] x [#] = $ [_____]
3. Technology / Law Library / Records: $ [_____]
4. Other Statutory Add-Ons: $ [_____]
   TOTAL TENDERED: $ [_____]

IX. SPECIAL NOTICES & CERTIFICATIONS

A. Electronic Filing: □ This case is being submitted through an approved e-Filing system (VJEFS/OCIS/Local).

B. Military Service Affidavit (if default possible):
 ☐ Attached ☐ Not Applicable

C. Compliance Certification:
 I certify that to the best of my knowledge, information, and belief formed after reasonable inquiry, this pleading is well-grounded in fact and law and is not interposed for any improper purpose.
 [Signature below satisfies Va. Sup. Ct. R. 1:4.]

X. SIGNATURE & DATE

Attorney / Pro Se Plaintiff: ____ Date: ___ / ___ /
(Printed Name): ________

Clerk’s Office Use Only

• Filing accepted on ___ / ___ / __ Initials:
• Receipt No.: _ Amount: $ __
• Case category code entered: ______
• Related cases cross-referenced: □ Yes □ N/A

[// GUIDANCE: 1. Attach the initial pleading (Complaint, Bill of Complaint, Petition, etc.) behind this sheet.
2. Provide sufficient copies for service and the court’s file.
3. Retain a copy for your records with clerk’s file-stamp.
4. Do not include social security numbers or full financial account numbers on this sheet; use the Confidential Addendum Form if required under Va. Code § 17.1-227.]