Appendix XI-X Verified Complaint - Nonpayment of Rent Revised 09/01/2016, CN 11252 (Appendix XI-X) page 1 NOTICE: This is a public document, which means the document as submitted will be available to the public upon request. Therefore, do not enter personal identifiers on it, such as Social Security number, driver222s license number, vehicle plate number, insurance policy number, active financial account number, or active credit card number. Plaintiff or Filing Attorney Information: Name NJ Attorney ID Number Address Telephone Number Superior Court of New Jersey Law Division, Special Civil Part County , Docket Number : LT Name of Plaintiff(s)/Landlord(s), Civil Action Verified Complaint Landlord/Tenant v. , Name of Defendant(s)/Tenant(s) . Non - payment of Rent Other (Required Notice s Attached) Address of Rental Premises: . Tenant222s Phone Number: . 1. The owner of record is (name of owner) . 2. Plaintiff is the owner or (check one) agent, assignee, grantee or prime tenant of the owner. 3. The landlord did did not acquire ownership of the property from the tenant(s). 4. The landlord has has not given the tenant(s) an option to purchase the property. 5. The tenant(s) now reside(s) in and has (have) been in possession of these premises sinc e (date) , under (check one) written or oral agreement 6. Check here if the tenancy is subsidized pursuant to either a federal or state program or the rental unit is public housing. 7. The landlord has registered the leasehold and notified tenant as required by N.J.S.A. 46:8 - 27. 8 . The amount that must be paid by the tenant(s) for these premises is $ , payable on the day of e ach month or week in advance . Complete Paragraphs 9A and 9B if Complaint is for Non-Payment of Rent American LegalNet, Inc. www.FormsWorkFlow.com Revised 09/01/2016, CN 11252 (Appendix XI-X) page 2 9A. There is due, unpaid and owing from tenant(s) to plaintiff/landlord rent as follows: $ base rent for (specify the week or month) $ base rent for (specify the week or month) $ base rent for (specify the week or month) $ late charge* for (specify the week or month) $ late charge* for (specify the week or month) $ late charge* for (specify the week or month) $ attorney fees* $ other* (specify) $ TOTAL * The late charges, attorney fees and other charges are permitted to be charged as rent for purposes of this action by federal, state and local law (including rent control and rent leveling) and by the lease. 9B . The date that the next rent is due is (date) . If this case is scheduled for trial before that date, the total amount you must pay to have this complaint dismissed is (Total from line 9A) $ . If this case is scheduled for trial on or after that date, the total amount you must pay to have this complaint dismissed is $ . ( Total from line 9A plus the amount of the next rent due ) These amounts do not include late fees or attorney fees for Section 8 and public housing tenants. Payment may be made to the landlord or the clerk of the court at any time before the trial date, but on the trial date payment must be made by 4:30 p.m. to get the case dismissed . Check Paragraphs 10 and 11 if the Complaint is for other than, or in addition to, Non-Payment of Rent. Attach All Notices to Cease and Notices to Quit/Demands For Possession. 10. Landlord seeks a judgment for possession for the additional or alternative reason(s) stated in the notices attached to this complaint. State Reasons : (Attach additional sheets if necessary.) 11. The tenant(s) has (have) not surrendered possession of the premises and tenant(s) hold(s) over and continue(s) in possession without the consent of landlord. WHEREFORE, plaintiff/landlord demands judgment for possession against the tenant(s) listed above, together with costs Dated : (Signature of Filing Attorney or Landlord Pro Se) (Printed or Typed Name of Attorney or Landlord Pro Se) American LegalNet, Inc. www.FormsWorkFlow.com Revised 09/01/2016, CN 11252 (Appendix XI-X) page 3 Landlord Verification 1. I certify that I am the landlord, general partner of the partnership, or authorized officer of a corporation or limited liability company that owns the premises in which tenant(s) reside(s). 2. I have read the verified complaint and the information contained in it is true and based on my personal knowledge. 3. The matter in controversy is not the subject of any other court action or arbitration proceeding now pending or contemplated and no other parties should be joined in this action except (list exceptions or indi cate none): . 4. I certify that confidential personal identifiers have been redacted from documents now submitted to the court, and will be redacted from all documents submitted in the future in accordance with Rule 1:38 - 7(b). 5 . The foregoing statements made by me are true and I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. At the trial plaintiff will require: An interpreter Yes No Indicate language An accommodation for a disability Yes No Required accommodation Dated: (Signature of Landlord, Partner or Officer) (Printed Name of Landlord, Partner or Officer) American LegalNet, Inc. www.FormsWorkFlow.com