Fill and Sign the 54 2g Form

Revised: 10/2012, 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 Plainti ff, 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 ot her party in this case? Yes No Plaintiff Defendant Name (last, first, middle initial) Name (last, first, middle initial) Social Security Number Date of Birth Place of Birth Social Security Number Date of Birth Place of Birth Address: Street 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 Name (or other income source) Employer Address: Street Employer Address: Street City State Zip City State Zip Professional, Occupational, Recreational Licenses (include types and license numbers) 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 Name Attorney Address: Street Attorney Address: Street City State Zip City State Zip Children Information Name (last, first, middle initial) Date of Birth Race Sex Social Security Number Place of Birth 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 forego ing statements made by me are wilfully false, I am subject to punishment. Date Signature