Form Ucs-840 - Request For Judicial Intervention Page 2
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1
2NATURE OF JUDICIAL INTERVENTION:
Check ONE box only AND enter additional information where indicated.
G
Infant's Compromise
G
Note of Issue and/or Certificate of Readiness
G
Notice of Medical, Dental, or Podiatric Malpractice
Date Issue Joined: _____________________________
G
Notice of Motion
Relief Sought: _________________________
Return Date: _____________________________
G
Notice of Petition
Relief Sought: _________________________
Return Date: _____________________________
G
Order to Show Cause
Relief Sought: _________________________
Return Date: _____________________________
G
Other Ex Parte Application
Relief Sought: _________________________
G
Poor Person Application
G
Request for Preliminary Conference
G
Residential Mortgage Foreclosure Settlement Conference
G
Writ of Habeas Corpus
G
Other (specify): _________________________________________________________________________________________________________
List any related actions. For Matrimonial actions, include any related criminal and/or Family Court cases.
RELATED CASES:
If additional space is required, complete and attach the RJI Addendum. If none, leave blank.
Case Title
Index/Case No.
Court
Judge (if assigned)
Relationship to Instant Case
For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in space provided.
PARTIES:
If additional space is required, complete and attach the RJI Addendum.
Parties:
Attorneys and/or Unrepresented Litigants
:
Issue
Un-
Insurance
List parties in caption order and
Provide attorney name, firm name, business address, phone number and e-mail
Joined
Rep
Carrier(s):
indicate party role(s) (e.g. defendant;
address of all attorneys that have appeared in the case. For unrepresented
(Y/N):
3rd-party plaintiff).
litigants, provide address, phone number and e-mail address.
Last Name
Last Name
First Name
G
YES
G
First Name
Firm Name
Primary Role:
Street Address
City
State
Zip
G
NO
Secondary Role (if any):
Phone
Fax
e-mail
Last Name
Last Name
First Name
G
YES
G
First Name
Firm Name
Primary Role:
Street Address
City
State
Zip
G
NO
Secondary Role (if any):
Phone
Fax
e-mail
Last Name
Last Name
First Name
G
YES
G
First Name
Firm Name
Primary Role:
Street Address
City
State
Zip
G
NO
Secondary Role (if any):
Phone
Fax
e-mail
Last Name
Last Name
First Name
G
YES
G
First Name
Firm Name
Primary Role:
Street Address
City
State
Zip
G
NO
Secondary Role (if any):
Phone
Fax
e-mail
I AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS NOTED ABOVE, THERE ARE AND HAVE
BEEN NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION PREVIOUSLY BEEN FILED IN
THIS ACTION OR PROCEEDING.
________________________________________________
Dated: _____________________________
SIGNATURE
________________________________________________
________________________________________________
ATTORNEY REGISTRATION NUMBER
PRINT OR TYPE NAME
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