SCANNED ON 713112009

t
b UCS-840 (REV 1/2000)
REQUEST FOR JUDLCIAL INTERVENTION

INDEX NO. DATE PURCHASED:

For Clerk Only
I

DEFENDANT (SI:

Date issue joined: Bill of particulars served ( Y / N ) :

.....................................................................................
NXKJRE OF JUDICIAL INTERvE#TION (check E box only
[

enter information)
]Yes
H?.- - . ..- .....
[ ] Request for preliminary conference [ ] Notice of petition (return date: )
Relief sought
[ ] Note of issue and/or certificate of
readiness [ ] Notice of medical or dental malpractick
action (specify: 1
[ 3 Notice of motion (return date: 1
Relief sought [ ] Statement of net worth
Order to show cause [ ] Writ of habeas corpus
I .

Relief sought [ ] Other (specify:

1
I

[ 3 Other ex parte application (specify:

{Check box only)

-
TQRTS
Malpractice-
[ ] Medical /Podiatric -m
[ I Dental - DM
C-IAL [ ] *Other Professional -0PM
[ ] Contract -coNT
[ ] Corporate -CORP J Motor Vehicle . -Mv
1 *Products Liability - PL
party, except a;b -INS
[ ] UCC (including -ucc 3 Environmental -EN
instluments) ] Asbestos -ASB
[ ] *Other Commerc -0c ] Breast Implant -BI
~
] *Other Negligence - OTN
m A L PRomTY [ 3 *Other Tort (including
[ ] Tax Certiorari -TAX intentionalI - OT
[ 3 Foreclosue -FOR
[ ] Condemnation -cow SPECIAL P R ~ I N G S
[ I Landlord/Tenant _-
-LT [ I Art. 75 (Arbitration) -ART75
[ ] *Other Real Property -0RP i j Art. 77 (Trusts) -ART77
[ ] u t . 78 -ART78
Election Law - ELEC
o m BmTrERs [ ] Guardianship (MHL Art. 81) -GUARD81
-0TH [ ] *Other Mental Hygiene -MHYG
[ I *
-OS?
* If asterisk used, p l c u e specify. [ ] *Other Special Proceeding

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 Is this action/proceeding against a
NO YES NO
[ 1 Municipality: [ ] [ ] Public Authority:
(Specify (Specify
YES NO
[ 1 *Does this action/proceedhg seek equitable relief?
[ I Does this action/proceeding seek recovery for personal injury?
[ I Does this action/proceeding seek recovery for property damage?
Pre-Note Time Frames:
(This applies to a l l cases except contested matrimmnial and tax certiorari cases)
Estimated time period far case to be ready for trial (from filing of R J I to filing of Note of Issu
ted: 0-8 months 0 Standard: 9-12 months 0 ccmpla: 13-15 months

Contested Matr-nial Cases Only: (Check and give date)

-
Self Name Address Phone #

*Self Represepted: parties representing themselves, without an attorney, sho

box and enter their name, address, -hone # in the space prwided above for a t t o r n e y s .

INsumNCB CARRIERS:

RELATED CASES: (IF m, w r i t e nXONIZ" below)

-
Title Index # -
court N a t u r e of Relationship-

bl o*
I~~ERplblpAtTpOFoKRJvRpTHAT,TOEIy~,oTIpERTBtANAsNoTEDAB
HAVE m # o R B L A T E D ACTIONS OR -=SI NOR HAS A R B
PRWIODSLY BKEN FILED IN THIS ACTION OR

Dated:
7

ATTACH RIDER SHEET IF -SsARp TO PROVIDE

\forms\ rji2000.wpd

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