REQUEST FOR JUDICIAL INTERVENTION For Court Clerk Use Only: IAS Entry Date UCS-840 (7/2012) 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: Check ONE box only and specify where indicated. MATRIMONIAL 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 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 NOTE: For Commercial Division assignment requests [22 NYCRR ' 202.70(d)], complete and attach the COMMERCIAL DIV RJI Addendum. Breast Implant Environmental: ________________________________________________ (specify) REAL PROPERTY: G G Medical, Dental, or Podiatric Malpractice How many properties does the application include? _________ Condemnation Motor Vehicle Mortgage Foreclosure (specify): G Residential G Commercial New York Products Liability:_______________________________________________ Property Address: ____________________________________________________ (specify) Street Address G Other Negligence:_______________________________________________ G Other Professional Malpractice:____________________________________ City (specify) G G Other Tort:_____________________________________________________G (specify) G (specify) Certificate of Incorporation/Dissolution [see NOTE under Commercial] Zip condominium, complete and attach the FORECLOSURE RJI Addendum. Tax Certiorari - Section: __________ Block: __________ Lot: __________ Tax Foreclosure Other Real Property:________________________________________________ (specify) OTHER MATTERS G G G G G G G G G State NOTE: For Mortgage Foreclosure actions involving a one- to four-family, owner-occupied, residential property, or an owner-occupied SPECIAL PROCEEDINGS 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 Other Mental Hygiene:______________________________________________ G Other Special Proceeding:___________________________________________ Emergency Medical Treatment CPLR Article 75 (Arbitration) Habeas Corpus CPLR Article 78 (Body or Officer) (specify) STATUS OF ACTION OR PROCEEDING: [see NOTE under Commercial] 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) (specify) (specify) (specify) Answer YES or NO for EVERY question AND enter additional information where indicated. YES 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 NO G G G 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 Date Issue Joined: _____________________________ Notice of Motion Relief Sought: _________________________ Return Date: _____________________________ Notice of Petition Relief Sought: _________________________ Return Date: _____________________________ Order to Show Cause Relief Sought: _________________________ Return Date: _____________________________ Other Ex Parte Application Relief Sought: _________________________ Poor Person Application Request for Preliminary Conference Residential Mortgage Foreclosure Settlement Conference Writ of Habeas Corpus 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. If additional space is required, complete and attach the RJI Addendum. Parties: Attorneys and/or Unrepresented Litigants: Issue Un- List parties in caption order and Insurance Provide attorney name, firm name, business address, phone number and e-mail Joined Rep indicate party role(s) (e.g. defendant; Carrier(s): 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. PARTIES: Last Name G Last Name First Name Primary Role: First Name G YES Firm Name Street Address City State Zip Secondary Role (if any): Phone Last Name G Fax e-mail Last Name First Name Primary Role: First Name G YES Firm Name Street Address City State Zip Secondary Role (if any): Phone Last Name G Fax Last Name First Name Primary Role: G NO e-mail First Name G YES Firm Name Street Address City State Zip Secondary Role (if any): Phone Last Name G G NO Fax e-mail Last Name First Name Primary Role: G NO First Name G YES Firm Name Street Address City State Zip Secondary Role (if any): Phone Fax G NO 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: _____________________________ ________________________________________________ ________________________________________________ ________________________________________________ ATTORNEY REGISTRATION NUMBER PRINT OR TYPE NAME SIGNATURE American LegalNet, Inc. www.FormsWorkFlow.com