For Court Clerk Use Only:
IAS Entry Date
REQUEST FOR JUDICIAL INTERVENTION
_________________________COUNTY________________________COURT,
Judge Assigned
Date Index Issued:________________________Index No: _____________________
RJI Date
Enter the complete case caption. Do not use et al or et ano.
CAPTION:
Defendant
Answer YES or NO, and provide additional information where indicated.
STATUS OF ACTION OR PROCEEDING:
If yes, date filed: ______________________________Has a summons been filed?
If yes, date served: ______________________________Has a summons been served?
If yes, complete and attach the MATRIMONIAL RJI Addendum (UCS-840M).
Are there children of the marriage under the age of 18?
EX PARTE APPLICATION FOR THE DISSOLUTION OF MARRIAGENATURE OF JUDICIAL INTERVENTION:
ADDITIONAL RELIEF: Check all that apply
Poor Person Application
Application for Alternate Service
Other (specify): ___________________________________________________________________________________________________________
For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in "Attorneys" space.
PARTIES:
(Y/N):
Joined
Issue
Attorneys and/or Unrepresented Litigants:Parties
Rep
Un-
For unrepresented litigants, provide litigant's address, phone number and e-mail address.
Provide attorney name, firm name, business address, phone number and e-mail address.
List party names.
N/A
First NameLast NameLast Name
G
Firm NameFirst Name
CityStreet AddressSuffixMiddle Name
e-mailFaxPhone
Role: PLAINTIFF
G NO
G YES
First NameLast NameLast Name
G
Firm NameFirst Name
CityStreet AddressSuffixMiddle Name
e-mailFaxPhone
Role: DEFENDANT
List any related cases, include any related criminal and/or Family Court cases.
RELATED CASES:
Relationship to Instant CaseJudge (if assigned)CourtIndex/Case No.Case Title
FILED IN THIS ACTION OR PROCEEDING.
HAVE BEEN NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION PREVIOUSLY BEEN
I AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS NOTED ABOVE, THERE ARE AND
________________________________________________
Dated: ______________________________
________________________________________________________________________________________________
ATTORNEY REGISTRATION NUMBER
ZipState
ZipState
UD-13
(rev. 5/2011)
