Confidential Litigant Information Sheet (R. 5:4-2(G))
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1Confidential Litigant Information Sheet (R. 5:4-2(g))
To Assure Accuracy of Court Records
To be filled out by plaintiff or defendant or attorney
Collection of the following information is pursuant to N.J.S.A. 2A:17-56.60 and R 5:7-4.
Confidentiality of this information must be maintained.
Docket #
CS
Your Name
:
(last, first, middle initial)
Are You:
Plaintiff or
Defendant?
Social Security
Date of Birth Place of Birth Driver’s License Number
(check one)
Number
(state of issuance)
Active Domestic Violence Order in this
case?
Yes or
No (check one)
Address
Telephone Number
Employer Name and Address (or other income source)
Telephone Number
Professional, Occupational, Recreational Licenses (Types and Numbers)
Attorney Name and Address
Rosanne S. DeTorres, Esq.
146 Main Street, Flemington, NJ 08822
Health Coverage for Children (available through parent filling out this form)
Health Care Provider
Policy #
Group #
Dental Care Provider
Policy #
Group #
Prescription Drug Provider
Policy #
Group #
Children Information
Social Security
Name (last, first, middle initial)
Date of Birth
Race
Sex
Place of Birth
Number
Sex
Race
Height
Weight
Eyes
Hair
Male
Auto License Plate #
Car (model, make, year) Mother’s maiden name and address
(State of issuance)
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by
me are wilfully false, I am subject to punishment.
__________________________________
__________________________________
Date
Signature
Easy Soft Effective Sept 1, 2009
Confidential Litigant Information Sheet
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Parent category: Legal