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RULE 7:8-7(b) CERTIFICATION APPLICATION FOR APPOINTMENT AS PRIVATE PROSECUTORState of New Jersey vs.___________________________________________________________________________ Docket Number(s):___________________________________________________________________________ Charge(s):___________________________________________________________________________ Attorney Information: Name:___________________________________________________________________________ Address___________________________________________________________________________ ___________________________________________________________________________ Telephone Number:___________________________________________________________________________ This Certification is supplied to the ____________________________________________________________________ Municipal Court, pursuant to the provisions of R. 7:8 -7(b) and State v. Storm, 141 N.J. 245 (1995) to provide the court and the prosecutor with all facts that may foreseeably affect the fairness of the proceedings to enable the court to determine whether I may be appointed as an impartial private prosecutor for________________________________ _______________________________________________, the complaining witness in the above matter. 1. (Please circle the applicable letter). The complaining witness is (a) an individual, (b) a business (please describe): _________________________________________________________________________________________________ or (c) an entity with its own police department (please describe): _______________________________________________ _________________________________________________________________________________________________ 2. There is no actual conflict of interest arising from my representation of, and fee arrangement with, the complaining witness. Check if correct. [ ] If not, please explain: _________________________________________________________________ _________________________________________________________________________________________________. 3. The municipal prosecutor has elected not to conduct the prosecution. Check if correct. [ ] If not, please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4. The defendant is or is expected to be represented by counsel. [ ] Yes [ ] No [ ] Unknown. Notice has been given to defendant’s attorney. [ ] Yes [ ] No 5. There is no civil litigation, existing or anticipated, between the complaining witness and the defendant concerning the same or similar facts as are contained in the complaint. In the event of such civil litigation, I have informed the complaining witness that neither I nor any member of my firm will undertake the complaining witness’ representation in that matter. Check if correct. [ ] If not, please explain: __________________________________________________________ ___________________________________________________________________________________________________ 6. There are no other facts that could reasonably affect the impartiality of the private prosecutor and the fairness of the proceedings or otherwise create an appearance of impropriety. Check if correct. [ ] If not, please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________. Comments: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please attach additional sheets, if necessary. CERTIFICATION IN LIEU OF OATHI hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. ________________________ _________________________________________ Date Name of Applicant (February, 1999)