Fillable 10486 Conf Lit Info Sheet (NJ Judiciary)

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10486 Conf Lit Info Sheet (NJ Judiciary)

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Revised: 11/2019, CN 10486 page 1 of 1
New Jersey Judiciary
Confidential Litigant Information Sheet (R. 5:4-2(g))
To assure accuracy of court records - To be filled out by Plaintiff, or Defendant, or Attorney
Collection of the following information is pursuant to N.J.S.A. 2A:17-56.60 and R. 5:7-4.
Confidentiality of this information must be maintained
Please complete the entire form, leaving no blank spaces. If something does not apply to you, enter “N/A”. This form is
confidential and will not be shared with the other party.
Docket Number:
CS Number:
Do you have an active Domestic Violence Order with the other party in this case?
Yes
No
Defendant
Name (last, first, middle initial)
Social Security Number
Date of Birth
Social Security Number
Date of Birth
Address: Street
City
State
Zip
City
State
Zip
Plaintiff Telephone Number
Employer Telephone Number
Defendant Telephone Number
Employer Telephone Number
Employer Name (or other income source)
Employer Address: Street
City
State
Zip
City
State
Zip
Professional, Occupational, Recreational Licenses
(include types and license numbers)
Driver's License Number
State of Issuance
Driver's License Number
State of Issuance
Sex
Race/Ethnicity
Height
Weight
Eyes
Hair
Sex
Race/Ethnicity
Height
Weight
Eyes
Hair
Auto: License Plate
State
Make
Model
Year
Auto: License Plate
State
Make
Model
Year
Attorney Name
Attorney Address: Street
City
State
Zip
City
State
Zip
Children Information
Name (last, first, middle initial)
Date of Birth
Race
Sex
Social Security Number
1.
2.
3.
4.
Health Coverage for Children - available through parent filling out this form ( Plaintiff / Defendant)
Health Care Provider:
Policy Number:
Group Number:
Health Care Provider:
Policy Number:
Group Number:
Health Care Provider:
Policy Number:
Group Number:
I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if any of the foregoing
statements made by me are wilfully false, I am subject to punishment.
Date
Signature
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10486 Conf Lit Info Sheet (NJ Judiciary)

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Completed 21 July 2020

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