Fill and Sign the Date Index Issued Form

For Court Clerk Use Only: UNCONTESTED MATRIMONIAL 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: Plaintiff -against- 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 MARRIAGE NATURE 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 Parties Rep Un- Provide attorney name, firm name, business address, phone number and e-mail address. List party names. N/A Name: G Role: PLAINTIFF G NO G YES Name: G Role: DEFENDANT List any related cases, include any related criminal and/or Family Court cases. RELATED CASES: Relationship to Instant Case Judge (if assigned) Court Index/Case No. Case Title THIS ACTION OR PROCEEDING. BEEN NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION PREVIOUSLY BEEN FILED IN I AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS NOTED ABOVE, THERE ARE AND HAVE ________________________________________________ Dated: ________/________/____________ SIGNATURE ________________________________________________ ________________________________________________ PRINT OR TYPE NAME ATTORNEY REGISTRATION NUMBER YES NO G G G G G G G G G UD-13 (rev. 5/2011)