Fill and Sign the Attorneypro Se Name Form

Revised Form Promulgated by 07/01/2019 Notice to the Bar, CN 10517 page 1 of 2 Appendix XII -B1 Civil Case Information Statement (CIS) Use for initial Law Division Civil Part pleadings (not motions) under Rule 4:5 -1 Pleading will be rejected for filing, under Rule 1:5- 6(c), if information above the black bar is not completed or attorney’s signature is not affixed For Use by Clerk’s Office Only Payment type: ck cg ca Chg/ Ck Number: Amount : Overpayment : Batch Number : Attorney/Pro Se Name Telephone Number County of Venue Firm Name (if applicable) Docket Number (when available) Office Address Document Type Jury Demand Yes No Name of Party (e.g., John Doe, Plaintiff) Caption Case Type Number (See reverse side for listing) Is this a professional malpractice case? Yes No If you have checked “Yes,” see N.J.S.A. 2A:53 A-27 and applicable case law regarding your obligation to file an affidavit of merit. Related Cases Pending? If “Yes,” list docket numbers Yes No Do you anticipate adding any parties Name of defendant’s primary insurance company (if known) (arising out of same transaction or occurrence)? None Yes No Unknown The Information Provided on This Form Cannot be Introduced into Evidence. Case Characteristics for Purposes of Determining if Case is Appropriate for Mediation Do parties have a current, past or recurrent relationship? If “Yes, ” is that relationship: Yes No Employer/Employee Friend/Neighbor Other (explain) Familial Business Does the statute governing this case provide for payment of fees by the losing party? Yes No Use this space to alert the court to any special case characteristics that may warrant individual management o r accelerated disposition Do you or your client need any disability accommodations? If yes, please identify the requested accommodation : Yes No Will an interpreter be needed? If yes, for what language? Yes No I certify that confidential personal identifiers have been redacted from documents now submitted to the court and will be redacted from all documents submitted in the future in accordance with Rule 1:38-7(b). Attorney Signature: Revised Form Promulgated by 07/01/2019 Notice to the Bar, CN 10517 page 2 of 2 Side 2 CIVIL CASE INFORMATION STATEMENT (CIS) Use for initial pleadings (not motions) under Rule 4:5 -1 CASE TYPES (Choose one and enter number of case type in appropriate space on the reverse side.) Track I - 150 days' discovery 151 NAME CHANGE 175 FORFEITURE 302 TENANCY 399 REAL PROPERTY (other than Tenancy, Contract, Condemnation, Complex Commercial or Construction) 502 BOOK ACCOUNT (debt collection matters only) 505 OTHER INSURANCE CLAIM (including declaratory judgment actions) 506 PIP COVERAGE 510 UM or UIM CLAIM (coverage issues only) 511 ACTION ON NEGOTIABLE INSTRUMENT 512 LEMON LAW 801 SUMMARY ACTION 802 OPEN PUBLIC RECORDS ACT (summary action) 999 OTHER (briefly describe nature of action) Track II - 300 days' discovery 305 CONSTRUCTION 509 EMPLOYMENT (other than CEPA or LAD) 599 CONTRACT/COMMERCIAL TRANSACTION 603N AUTO NEGLIGENCE – PERSONAL INJURY (non -verbal threshold) 603Y AUTO NEGLIGENCE – PERSONAL INJURY (verbal threshold) 605 PERSONAL INJURY 610 AUTO NEGLIGENCE – PROPERTY DAMAGE 621 UM or UIM CLAIM (includes bodily injury) 699 TORT – OTHER Track III - 450 days' discovery 005 CIVIL RIGHTS 301 CONDEMNATION 602 ASSAULT AND BATTERY 604 MEDICAL MALPRACTICE 606 PRODUCT LIABILITY 607 PROFESSIONAL MALPRACTICE 608 TOXIC TORT 609 DEFAMATION 616 WHISTLEBLOWER / CONSCIENTIOUS EMPLOYEE PROTECTION ACT (CEPA) CASES 617 INVERSE CONDEMNATION 618 LAW AGAINST DISCRIMINATION (LAD) CASES Track IV - Active Case Management by Individual Judge / 450 days' discover y 156 ENVIRONMENTAL/ENVIRONMENTAL COVERAGE LITIGATION 303 MT. LAUREL 508 COMPLEX COMMERCIAL 513 COMPLEX CONSTRUCTION 514 INSURANCE FRAUD 620 FALSE CLAIMS ACT 701 ACTIONS IN LIEU OF PREROGATIVE WRITS Multicounty Litigation (Track IV) 271 ACCUTANE/ISOTRETINOIN 297 MIRENA CONTRACEPTIVE DEVICE 274 RISPERDAL/SEROQUEL/ZYPREXA 299 OLMESARTAN MEDOXOMIL MEDICATIONS /BENICAR 281 BRISTOL -MYERS SQUIBB ENVIRONMENTAL 300 TALC -BASED BODY POWDERS 282 FOSAMAX 601 ASBESTOS 285 STRYKER TRIDENT HIP IMPLANTS 623 PROPECIA 286 LEVAQUIN 624 STRYKER LFIT CoCr V40 F EMORAL HEADS 289 REGLAN 625 FIREFIGHTER HEARING LOSS LITIGATION 291 PELVIC MESH/GYNECARE 626 ABILIFY 292 PELVIC MESH/BARD 627 PHYSIOMESH FLEXIBLE COMPOSITE MESH 293 DEPUY ASR HIP IMPLANT LITIGATION 628 TAXOTERE/DOCETAXEL 295 ALLODERM REGENERATIVE TISSUE MATRIX 629 ZOSTAVAX 296 STRYKER REJUVENATE/ABG II MODULAR HIP STEM COMPONENTS 630 PROCEED MESH/PATCH If you believe this case requires a track other than that provided above, please indicate the reason on Side 1, in the space under "Case Characteristics. Please check off each applicable category Putative Class Action Title 59