NOTE OF ISSUE
Calendar No. (if any)
For use of Clerk
Index No.
Court,
County, N.Y.
Nam e of Justice Assigned
NOTICE FOR TRIAL
Trial by jury dem anded
Of all issues
Of issues specified below
Or attached hereto
Plaintiff/Petitioner
Trial without Jury
Filed by
Date sum m ons served
Date service com pleted
-against-
Date Issue joined
NATURE OF ACTION OR PROCEEDING
Tort
Motor Vehicle Negligence
Medical Malpractice
Other Tort
Contract
Contested Matrim onial
Uncontested Matrim onial
Tax Certiorari
Condem nation
Other (not item ized above) specify:
Defendant/Respondent
This action is brought as a class action
Am ount Dem anded $
Other Relief
Special Preference claim ed under
Insurance carrier(s), if known:
on the ground that
Attorney for Plaintiff/Plaintiff Pro Se:
Address:
Phone Num ber
Attorney for Defendant/Defendant Pro Se:
Address:
Phone Num ber