Date that notice of entry of judgment or a copy of the judgment was served by the clerk or by a party under California Rules of
Court, rule 8.104:
Form Adopted for Mandatory Use
Judicial Council of California
APP-004 [Rev. January 1, 2017]
PART I – APPEAL INFORMATION
APPEALABILITY
NOTE TO APPELLANT: You must file this form with the clerk of the Court of Appeal within 15 days after the clerk mails you
the notification of the filing of the notice of appeal required under rule 8.100(e)(1). You must attach to this form a copy of the
judgment or order being appealed that shows the date it was entered (see Cal. Rules of Court, rule 8.104 for definition of
"entered"). A copy of this form must also be served on the other party or parties to this appeal. (CAUTION: An appeal in a
limited civil case (Code Civ. Proc., § 85) may be taken ONLY to the appellate division of the superior court (Code Civ. Proc., §
904.2) or to the superior court (Code Civ. Proc., § 116.710 [small claims cases]).
Appeal is from:
Page 1 of 4
CIVIL CASE INFORMATION STATEMENT
(Appellate)
TIMELINESS OF APPEAL (Provide all applicable dates.)
Was a motion for new trial, for judgment notwithstanding the verdict, for reconsideration, or to vacate the judgment made and
denied?
Does the judgment appealed from dispose of all causes of action, including all cross-actions between the parties?
BANKRUPTCY OR OTHER STAY
Is there a related bankruptcy case or a court-ordered stay that affects this appeal?
(If yes, please attach a copy of the bankruptcy petition [without attachments] and
any stay order.)
www.courts.ca.gov
Judgment after court trial
Default judgment
Judgment after an order granting a summary judgment motion
Judgment of dismissal under Code Civ. Proc., § 581d, 583.250, 583.360, or 583.430
Judgment of dismissal after an order sustaining a demurrer
An order after judgment under Code Civ. Proc., § 904.1(a)(2)
An order or judgment under Code Civ. Proc., § 904.1(a)(3)–(13)
(describe and specify code section that authorizes this appeal):
Other
(If no, please explain why the judgment is appealable):
Yes No
Date of entry of judgment or order appealed from:
(If yes, please specify the type of motion):
Yes No
Judgment after jury trial
APPELLANT:
RESPONDENT:
FOR COURT USE ONLY
SUPERIOR COURT CASE NUMBER:
CIVIL CASE INFORMATION STATEMENT
APP-004
TO BE FILED IN THE COURT OF APPEAL
COURT OF APPEAL CASE NUMBER (if known):
ATTORNEY OR PARTY WITHOUT ATTORNEY:
STATE: ZIP CODE:CITY:
STREET ADDRESS:
FIRM NAME:
NAME:
STATE BAR NO:
TELEPHONE NO.:
FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):
APPELLATE DISTRICT, DIVISION COURT OF APPEAL,
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
BRANCH NAME:
CITY AND ZIP CODE:
STREET ADDRESS:
MAILING ADDRESS:
JUDGES (all who
participated in case):
Date notice of intention to move for new trial (if any) filed:
Date motion filed: Date motion denied: Date denial served:
Date notice of
appeal or cross-appeal filed:
Yes No
A.
1.
2.
B.
1.
2.
3.
4.
C.
SERVICE REQUIREMENTS
Is service of documents in this matter, including a notice of appeal, petition, or brief, required on the Attorney General or other
nonparty public officer or agency under California Rules of Court, rule 8.29 or a statute?
NOTE: The rule and statutory provisions listed above require service of a copy of a party's notice of appeal, petition, or brief
on the Attorney General or other public officer or agency. Other statutes requiring service on the Attorney General or other
public officers or agencies may also apply.
PART lI – NATURE OF ACTION
Nature of action (check all that apply):
A.
1.
2.
3.
4. a. b.
(If yes, please indicate the rule or statute that applies)
Yes No
5.
6.
7.
8. a. b.
9.
a. b.
c. d.
e.
10.
11.
Writ proceedings in superior court
a. b.
c. d.
12.
B.
APPELLATE CASE HISTORY (Provide additional information, if necessary, on attachment I.D.) Is there now, or has there
previously been, any appeal, writ, or other proceeding related to this case pending in any California appellate court?
(If yes, insert name of appellate court):
Yes No
Appellate court case no.: Title of case:
Name of trial court: Trial court case no.:
Rule 8.29 (e.g., constitutional challenge; state or county party)
Bus. & Prof. Code, §16750.2 (Antitrust)
Gov. Code, § 946.6(d) (Actions against public entities)
Bus. & Prof. Code, § 17209 (Unfair Competition Act)
Gov. Code, § 4461 (Disabled access to public buildings)
Bus. & Prof. Code, § 17536.5 (False advertising)
Gov. Code, § 12656(a) (False Claims Act)
Civ. Code, § 51.1 (Unruh, Ralph, or Bane Civil Rights
Acts; antiboycott cause of action; sexual harassment in
business or professional relations; civil rights action by
district attorney)
Health & Saf. Code, § 19959.5 (Disabled access to
privately funded public accommodations)
Civ. Code, § 55.2 (Disabled access to public
conveyances, accommodations, and housing)
Pub. Resources Code, § 21167.7 (CEQA)
Health & Saf. Code, § 19954.5 (Accessible seating and
accommodations)
Other (specify statute):
Conservatorship
Contract
Eminent domain
Equitable action Declaratory relief Other
(describe):
Family law
Guardianship
Probate
Real property rights Title of real property
(describe):
Other
Tort
Medical malpractice Product liability
Other personal injury Personal property
Other tort
(describe):
Mandate (Code Civ. Proc., § 1085)
Administrative mandate (Code Civ. Proc., § 1094.5)
Prohibition (Code Civ. Proc., § 1102)
Other
(describe):
Other action
(describe):
This appeal is entitled to calendar preference/priority on appeal
(cite authority):
APP-004 [Rev. January 1, 2017]
Page 2 of 4
CIVIL CASE INFORMATION STATEMENT
(Appellate)
D.
E.
Code Civ. Proc., § 1355 (Escheat)
Trust proceedings
APP-004
APPELLATE COURT CASE NUMBER:APPELLATE CASE TITLE:
This statement is prepared and submitted by:
(SIGNATURE OF ATTORNEY OR SELF-REPRESENTED PARTY)
Page 3 of 4
CIVIL CASE INFORMATION STATEMENT
(Appellate)
PART III – PARTY AND ATTORNEY INFORMATION
In the spaces below or on a separate page or pages, list all the parties and all their attorneys of record who will participate in the
appeal. For each party, provide all of the information requested on the left side of the page. On the right side of the page, if a party is
self-represented please check the appropriate box and provide the party's mailing address, telephone number, fax number, and e-
mail address. If a party is represented by an attorney, on the right side of the page, check the appropriate box and provide all of the
requested information about that party's attorney.
Responses to Part III are attached instead of below
Additional pages attached
Date:
APP-004
APPELLATE COURT CASE NUMBER:APPELLATE CASE TITLE:
Appellant Respondent
Trial court designation:
Plaintiff
Defendant
Name of Party:
Appellate court designation:
(specify):
Other
Self-represented
Name of attorney:
State Bar no:
Firm name:
Mailing address:
Telephone no.: Fax no:
E-Mail address:
Represented by attorney
Appellant Respondent
Trial court designation:
Plaintiff
Defendant
Name of Party:
Appellate court designation:
(specify):
Other
Self-represented
Name of attorney:
State Bar no:
Firm name:
Mailing address:
Telephone no.: Fax no:
E-Mail address:
Represented by attorney
Appellant Respondent
Trial court designation:
Plaintiff
Defendant
Name of Party:
Appellate court designation:
(specify):
Other
Self-represented
Name of attorney:
State Bar no:
Firm name:
Mailing address:
Telephone no.: Fax no:
E-Mail address:
Represented by attorney
Appellant Respondent
Trial court designation:
Plaintiff
Defendant
Name of Party:
Appellate court designation:
(specify):
Other
Self-represented
Name of attorney:
State Bar no:
Firm name:
Mailing address:
Telephone no.: Fax no:
E-Mail address:
Represented by attorney
APP-004 [Rev. January 1, 2017]
Page 4 of 4APP-004 [Rev. January 1, 2017]
I mailed, personally delivered, or electronically served a copy of the Civil Case Information Statement (Appellate) as follows
(complete a, b, or c):
I enclosed a copy in an envelope and(1)
(a)
(b)
The envelope was addressed and mailed as follows:
deposited the sealed envelope with the United States Postal Service, with the postage fully prepaid.
placed the envelope for collection and mailing on the date and at the place shown in items below, following our
ordinary business practices. I am readily familiar with this business's practice for collecting and processing
correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is
deposited in the ordinary course of business with the United States Postal Service, in a sealed envelope with
postage fully prepaid.
Name of person served:
Address on envelope:
Date of mailing:
Place of mailing (city and state):
(2)
(a)
(b)
(c)
(d)
At the time of service I was at least 18 years of age.
PROOF OF SERVICE
a.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
b.
Name of person served:
Address where delivered:
Date delivered:
Time delivered:
(1)
(2)
(3)
(4)
Personal delivery. I am not a party to this legal action. I personally delivered a copy as follows:
NOTICE TO PARTIES: A copy of this form must be served on the other party or parties to this appeal. If served by mail or personal
delivery, A PARTY TO THE APPEAL MAY NOT PERFORM THE MAILING OR DELIVERY HIMSELF OR HERSELF. Electronic
service is authorized only if ordered by the court or if the party served has agreed to accept electronic service. A person who is at
least 18 years old must complete the information below and serve all pages of this document. When all pages of this document
have been completed and a copy served, the original may then be filed with the court.
Electronic Service
Mail Personal Service
My residence or business address is (specify):
(TYPE OR PRINT NAME)
(SIGNATURE OF DECLARANT)
Date:
Mail. I am a resident of or employed in the county where the mailing occurred and am not a party to this legal action.
1.
2.
3.
CIVIL CASE INFORMATION STATEMENT
(Appellate)
APP-004
APPELLATE COURT CASE NUMBER:APPELLATE CASE TITLE:
c.
Name of person served:
Electronic service address of person served:
On (date):
(1)
(2)
(3)
Electronic service.
My electronic service address is (specify):
I electronically served a copy as follows:
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