UNCONTESTED MATRIMONIAL For Court Clerk Use Only:

UD-13 IAS Entry Date

REQUEST FOR JUDICIAL INTERVENTION (rev. 5/2011)

________________________COURT, _________________________COUNTY
Judge Assigned
Index No: _____________________ Date Index Issued:______/______/__________
RJI Date
CAPTION: Enter the complete case caption. Do not use et al or et ano.

Plaintiff
-against-

Defendant

STATUS OF ACTION OR PROCEEDING: Answer YES or NO, and provide additional information where indicated.
YES NO
Has a summons been filed? G G If yes, date filed: ________/________/____________
Has a summons been served? G G If yes, date served: ________/________/____________
Are there children of the marriage under the age of 18? G G If yes, complete and attach the MATRIMONIAL RJI Addendum (UCS-840M).

NATURE OF JUDICIAL INTERVENTION: EX PARTE APPLICATION FOR THE DISSOLUTION OF MARRIAGE

ADDITIONAL RELIEF: Check all that apply
G Poor Person Application
G Application for Alternate Service
G Other (specify): _____________________________________________________________________________________________________________

PARTIES: For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in "Attorneys" space.
Parties Attorneys Issue
Un-
Joined
Rep List party names. Provide attorney name, firm name, business address, phone number and e-mail address. (Y/N):
Name:

G N/A

Role: PLAINTIFF
Name:

G YES
G G NO
Role: DEFENDANT

RELATED CASES: List any related cases, include any related criminal and/or Family Court cases.
Case Title Index/Case No. Court Judge (if assigned) Relationship to Instant Case

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