REQUEST FOR JUDICIAL INTERVENTION For Court Clerk Use Only:

UCS-840 (7/2012) IAS Entry Date

Supreme
________________________COURT, COUNTY OF___________________________
Judge Assigned
Index No: _____________________ Date Index Issued:___________________

Enter the complete case caption. Do not use et al or et ano. If more space is required, RJI Date
CAPTION: 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 COMMERCIAL
G Contested G Business Entity (including corporations, partnerships, LLCs, etc.)
NOTE: For all Matrimonial actions where the parties have children under G Contract
the age of 18, complete and attach the MATRIMONIAL RJI Addendum. G Insurance (where insurer is a party, except arbitration)
For Uncontested Matrimonial actions, use RJI form UD-13. G UCC (including sales, negotiable instruments)
TORTS G Other Commercial:_________________________________________________
G Asbestos (specify)

G Breast Implant NOTE: For Commercial Division assignment requests [22 NYCRR '
G Environmental: ________________________________________________ 202.70(d)], complete and attach the COMMERCIAL DIV RJI Addendum.
(specify)
REAL PROPERTY: How many properties does the application include? _________
G Medical, Dental, or Podiatric Malpractice G Condemnation
G Motor Vehicle G
Mortgage Foreclosure (specify): G Residential G Commercial
G Products Liability:_______________________________________________ Property Address: ____________________________________________________
(specify) Street Address City State Zip
G Other Negligence:_______________________________________________ NOTE: For Mortgage Foreclosure actions involving a one- to four-family,
(specify) owner-occupied, residential property, or an owner-occupied
G Other Professional Malpractice:____________________________________ condominium, complete and attach the FORECLOSURE RJI Addendum.
(specify)
G Tax Certiorari - Section: __________ Block: __________ Lot: __________
G Other Tort:_____________________________________________________G Tax Foreclosure
(specify)
G Other Real Property:________________________________________________
(specify)
OTHER MATTERS
G Certificate of Incorporation/Dissolution [see NOTE under Commercial] SPECIAL PROCEEDINGS
G Emergency Medical Treatment G CPLR Article 75 (Arbitration) [see NOTE under Commercial]
G Habeas Corpus G CPLR Article 78 (Body or Officer)
G Local Court Appeal G Election Law
G Mechanic's Lien G MHL Article 9.60 (Kendra's Law)
G Name Change G MHL Article 10 (Sex Offender Confinement-Initial)
G Pistol Permit Revocation Hearing G MHL Article 10 (Sex Offender Confinement-Review )
G Sale or Finance of Religious/Not-for-Profit Property G MHL Article 81 (Guardianship)
G Other:________________________________________________________ G Other Mental Hygiene:______________________________________________
(specify) (specify)
G Other Special Proceeding:___________________________________________
(specify)
(specify)
STATUS OF ACTION OR PROCEEDING: Answer YES or NO for EVERY question AND enter additional information where indicated.
YES NO
Has a summons and complaint or summons w/notice been filed? G G If yes, date filed: _____________________________
Has a summons and complaint or summons w/notice been served? G G If yes, date served: _____________________________
Is this action/proceeding being filed post-judgment? G G If yes, judgment date: _____________________________
NATURE OF JUDICIAL INTERVENTION: Check ONE box only AND enter additional information where indicated.
G Infant's Compromise
G Note of Issue and/or Certificate of Readiness
G Notice of Medical, Dental, or Podiatric Malpractice Date Issue Joined: _____________________________
G Notice of Motion Relief Sought: _________________________ Return Date: _____________________________
G Notice of Petition Relief Sought: _________________________ Return Date: _____________________________
G Order to Show Cause Relief Sought: _________________________ Return Date: _____________________________
G Other Ex Parte Application Relief Sought: _________________________
G Poor Person Application
G Request for Preliminary Conference
G Residential Mortgage Foreclosure Settlement Conference
G Writ of Habeas Corpus
G 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.
PARTIES: 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 Provide attorney name, firm name, business address, phone number and e-mail Insurance
Joined
Rep indicate party role(s) (e.g. defendant; address of all attorneys that have appeared in the case. For unrepresented Carrier(s):
(Y/N):
3rd-party plaintiff). litigants, provide address, phone number and e-mail address.

Last Name Last Name First Name

G YES

G First Name
Primary Role:
Firm Name

Street Address City State Zip

Secondary Role (if any): G NO
Phone Fax e-mail

Last Name Last Name First Name

G YES

G First Name
Primary Role:
Firm Name

Street Address City State Zip

Secondary Role (if any): G NO
Phone Fax e-mail

Last Name Last Name First Name

G YES

G First Name
Primary Role:
Firm Name

Street Address City State Zip

Secondary Role (if any): G NO
Phone Fax e-mail

Last Name Last Name First Name

G YES

G First Name
Primary Role:
Firm Name

Street Address City State Zip

Secondary Role (if any): G NO
Phone 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 PRINT OR TYPE NAME
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