Confidential Litigant Information Sheet (R. 5:4-2(G)) - Fillable
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Confidential 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? (circle
Social Security Number
Date of Birth
Place of Birth
Driver's License Number
one)
(state of issuance)
-
-
Active Domestic Violence Order in this
case? Yes or no (circle 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
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
Name (last, first, middle initial)
Date of Birth
Race
Sex
Social Security Number
Place of Birth
1.
2.
3.
4.
5.
6.
Sex
Race
Height
Weight
Eyes
Hair
Auto License Plate #
Car
Mother's maiden name and address
(State of issuance)
(model, make, year)
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
Note: Form adopted July 28, 2004 to be effective September 1, 2004; amended June 15, 2007 to be effective September 1, 2007.
Revised: 9/2007, CN: 10486-English
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