REQUEST FOR JUDICIAL INTERVENTION UCS-840 (7/2012) For Court Clerk Use Only: IAS Entry Date Supreme ________________________COURT, COUNTY OF___________________________ Judge Assigned Index No: _____________________ CAPTION: Date Index Issued:___________________ RJI Date Enter the complete case caption. Do not use et al or et ano. If more space is required, attach a caption rider sheet. Plaintiff(s)/Petitioner(s) -against- Defendant(s)/Respondent(s) NATURE OF ACTION OR PROCEEDING: MATRIMONIAL Check ONE box only and specify where indicated. G COMMERCIAL Contested NOTE: For all Matrimonial actions where the parties have children under the age of 18, complete and attach the MATRIMONIAL RJI Addendum. For Uncontested Matrimonial actions, use RJI form UD-13. TORTS G G G G G G G G G G G G G Business Entity (including corporations, partnerships, LLCs, etc.) Contract Insurance (where insurer is a party, except arbitration) UCC (including sales, negotiable instruments) Other Commercial:_________________________________________________ (specify) Asbestos Breast Implant Environmental: ________________________________________________ (specify) NOTE: For Commercial Division assignment requests [22 NYCRR ' 202.70(d)], complete and attach the COMMERCIAL DIV RJI Addendum. REAL PROPERTY: Medical, Dental, or Podiatric Malpractice Motor Vehicle Mortgage Foreclosure (specify): G Residential G Commercial New York Products Liability:_______________________________________________ Property Address: ____________________________________________________ (specify) Street Address City State Zip G G How many properties does the application include? _________ Condemnation Other Negligence:_______________________________________________ (specify) NOTE: For Mortgage Foreclosure actions involving a one- to four-family, owner-occupied, residential property, or an owner-occupied condominium, complete and attach the FORECLOSURE RJI Addendum. Tax Certiorari - Section: __________ Block: __________ Lot: __________ Tax Foreclosure Other Real Property:________________________________________________ (specify) G G Other Tort:_____________________________________________________G (specify) G (specify) Other Professional Malpractice:____________________________________ OTHER MATTERS G G G G G G G G G G G Local Court Appeal G Mechanic's Lien G Name Change G Pistol Permit Revocation Hearing G Sale or Finance of Religious/Not-for-Profit Property G Other:________________________________________________________ G Emergency Medical Treatment Habeas Corpus (specify) Certificate of Incorporation/Dissolution [see NOTE under Commercial] SPECIAL PROCEEDINGS CPLR Article 75 (Arbitration) Election Law MHL Article 9.60 (Kendra's Law) MHL Article 10 (Sex Offender Confinement-Initial) MHL Article 10 (Sex Offender Confinement-Review) MHL Article 81 (Guardianship) Other Mental Hygiene:______________________________________________ (specify) [see NOTE under Commercial] CPLR Article 78 (Body or Officer) G Other Special Proceeding:___________________________________________ (specify) (specify) STATUS OF ACTION OR PROCEEDING: Answer YES or NO for EVERY question AND enter additional information where indicated. Has a summons and complaint or summons w/notice been filed? Has a summons and complaint or summons w/notice been served? Is this action/proceeding being filed post-judgment? G G G YES G G G NO If yes, date filed: _____________________________ If yes, date served: _____________________________ If yes, judgment date: _____________________________ American LegalNet, Inc. www.FormsWorkFlow.com NATURE OF JUDICIAL INTERVENTION: G G G G G G G G G G G G Check ONE box only AND enter additional information where indicated. Infant's Compromise Note of Issue and/or Certificate of Readiness Notice of Medical, Dental, or Podiatric Malpractice Notice of Motion Notice of Petition Order to Show Cause Other Ex Parte Application Poor Person Application Request for Preliminary Conference Residential Mortgage Foreclosure Settlement Conference Writ of Habeas Corpus Date Issue Joined: _____________________________ Return Date: _____________________________ Return Date: _____________________________ Return Date: _____________________________ Relief Sought: _________________________ Relief Sought: _________________________ Relief Sought: _________________________ Relief Sought: _________________________ 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 PARTIES: Parties: For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in space provided. If additional space is required, complete and attach the RJI Addendum. Attorneys and/or Unrepresented Litigants: Provide attorney name, firm name, business address, phone number and e-mail address of all attorneys that have appeared in the case. For unrepresented litigants, provide address, phone number and e-mail address. Last Name First Name Un- List parties in caption order and Rep indicate party role(s) (e.g. defendant; 3rd-party plaintiff). Last Name Issue Joined (Y/N): Insurance Carrier(s): G YES G First Name Primary Role: Street Address Secondary Role (if any): Phone Firm Name City State Zip G NO Fax e-mail Last Name Last Name First Name G YES G First Name Primary Role: Street Address Secondary Role (if any): Phone Firm Name City State Zip G NO Fax e-mail Last Name Last Name First Name G YES G First Name Primary Role: Street Address Secondary Role (if any): Phone Firm Name City State Zip G NO Fax e-mail Last Name Last Name First Name G YES G First Name Primary Role: Street Address Secondary Role (if any): Phone Firm Name City State Zip G NO 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 __________________________________________