UCS-840 REQUEST FOR JUDICIAL INTERVENTION(REV 1/2000)

Clerk to fill outIndex No. Date PurchasedCountyCourt

PLAINTIFF(S): IAS entry date

Judge AssignedDEFENDANT(S):

RJI Date

YesBill of Particulars served: NoDate issue joined:

NATURE OF JUDICIAL INTERVENTION (Check one box only and enter information)Request for Preliminary Conference Notice of Petition (return date: )Note of Issue and/or Certificate of Readiness Relief sought:

Notice of Medical or Dental Malpractice ActionNotice of Motion (return date:Relief sought: (Specify: )

Statement of Net WorthOrder to Show CauseWrit of Habeas Corpus(Clerk enter return date: )

Relief sought: Other (Specify:Other Ex Parte Application

)

)

NATURE OF ACTION OR PROCEEDING (Check one box only)Matrimonial Torts

-CM -MMContested Medical/Podiatric Malpractice-UM -DMUncontested Dental Malpractice

-OPMOther Professional MalpracticeCommercial

-CONT -MVContract Motor Vehicle-CORP -PLCorporate Products Liability-INSInsurance

-EN(where insurer is a party, except arbitration) Environmental-ASBLICC Asbestos-UCC-BI(including sales, negotiable instruments) Breast Implant

-OC -OTNOther Commercial Other Negligence

-OTOther Tort (including intentional)Real Property

-TAXTax Certiorari-FORForeclosure Special Proceedings-COND -ART75Condemnation Art. 75 (Arbitration)-LT -ART77Landlord/Tenant Art. 77 (Trusts)-ORP -ART78Other Real Property Art. 78

-ELECElection Law-GUARD81Guardianship (MHL Art. 81)-MHYGOther Matters Other Mental Hygiene

-OTH -OSPOther Special Proceeding

)

(Specify:

InstructionsCourt - put the name of the court where you filed or will file your court action/proceeding. For example, Supreme or County Court.County - put the name of the county where you filed or will file your court action/proceeding.Index No. - put the Index No. assigned by the County Clerk. You must have an Index No. before you file your RJI.Date Purchased - put the date you purchased your Index No. from the County Clerk. If you were granted poor person status and didn't have to pay, put the date the Index No. was assigned to your action/proceeding.

InstructionsPut your name and the names of any other individuals, business and/or company bringing the action.

InstructionsPut the name of the person(s), business and/or company you are bringing your action against (who you are suing).

InstructionsPut the date the Defendant filed an answer or response to your action/proceeding. If there is more than one Defendant, put the date for the first answer/response filed.

InstructionsCheck whether or not the Defendant served you with a Demand for Bill of Particulars. This is a document demanding more details or clarification as to the basis of your action.

EXPLANATION OF CHOICES ON RJI FORM

Nature of Judicial Intervention

Choose one box that best describes why you need a judge assigned to your case. Some boxesneed additional information, such as a return date or relief sought. The return date is when aresponse to the papers you are filing, such as a motion or a petition, is due from the defendant orpossibly when you would appear before the judge to argue your case. This date is provided by thejudge or clerk. Relief sought is what you are seeking from the court, such as money from thedefendant. Listed below are the choices under this section and an explanation of each.

Request for Preliminary Conference: You arerequesting an initial hearing with the judge.

Note of Issue and/or Certificate of Readiness:You are telling the court that you are ready togo to trial.

Notice of Motion: You are filing papers askingthe judge to decide on certain issue(s) in yourcase. For example, you want the court toorder the defendant to turn over financialrecords. The relief sought would be for thecourt to order the defendant to give you thefinancial records.

Order to Show Cause: You are seeking awritten order from the judge telling someoneto go to court on a certain day to give legaland/or factual reasons why an order shouldnot be made giving you the relief asked for.

Other Ex Parte Application: A proceeding,order, motion, application or request made byor granted without another party first beingnotified.

Notice of Petition: You are filing papersasking for a hearing to decide on the reliefrequested in the petition, which is a formalwritten request to the court.

Notice of Medical or Dental MalpracticeAction: Your case involves medical or dentalnegligence.

Statement of Net Worth: You are filing astatement that tells the court what yourassets and liabilities are. Your assets areitems worth money $ and a liability is anobligation or debt.

Writ of Habeas Corpus: You are filing papersseeking relief from unlawful detention(incarceration in a jail, correctional facility orpenitentiary) for yourself or another person.

Other: Any other reason you are asking thata judge be assigned to your case that doesnot fall under the other reasons. You must tellthe court what that reason is.

Nature of Action or Proceeding

Choose the box that best describes your case. If you think your case could be under more than onecategory, then choose the category you think best fits your lawsuit, as you can only mark one box.Selecting one of the boxes now will not prevent you from changing the nature of your action as yourcase progresses.

Matrimonial: Divorce cases.

Contested - A divorce action that is opposedby the other spouse. The other spouse maynot want a divorce, or you and your spousemay not agree on certain issues of thedivorce which may need the court's decision.

Uncontested - This is a divorce action whereyou don't expect any disagreements or youthink your spouse may not go to court.

Commercial: Business or corporate related cases.

Contract - A contract is a written or oralagreement between two or more people/parties which can be enforced by law.

Corporate - This is a dispute involving acorporation, which is an organization formedwith state approval to act as an artificialperson to carry on business and/or otheractivities.

Insurance (where insurer is a party, exceptarbitration) - A dispute with an insurancecompany. This can include denial of a claim,greatly undervaluing a claim and/or delayingpayment of a claim.

UCC (including sales, negotiable instruments)- UCC stands for Uniform Commercial Codeand deals with the laws of sales and othercommercial transactions. This can includethe sale and leasing of goods, checks anddrafts, letters of credit, auctions andliquidations, the shipment and storage ofgoods, and investment securities andfinancial transactions.

Other Commercial - A case involving abusiness or corporation that doesn't fit intothe other categories listed above. This mayinclude hiring practices and manufacturingand sales.

Real Property: Cases involving real estate.

Tax Certiorari - This is the process aproperty owner can use to challenge the valueplaced on property (estate tax assessment )to try to reduce the assessed value and thetaxes on it.

Foreclosure - This is the process a bank orother secured creditor uses to sell orrepossess real property because the ownerdidn't pay their mortgage, taxes or otherinsurance on the property.

Condemnation - This is the process amunicipality (a city, town or villageincorporated for local government) uses to

attempt to take private property for public usewithout the owners consent, although theowner will be compensated for the property.

Landlord/Tenant - This is a dispute between alandlord and tenant which may require thecourt to step in, such as evictions. This canalso be referred to as unlawful detainer,summary possession, forcible detainer,ejectment and repossession.

Other Real Property - A case involving realproperty that doesn't fit into any of the othercategories listed above, such as ownership,easement and right-of-way.

Other Matters: Any other reason to bring a lawsuit that doesn't fall under the other categories.

Torts: A civil wrong which usually involves personal injury or loss of property in some way.

Medical/Podiatric Malpractice - Neglect by ahealthcare provider, such as a physician, thatcauses injury. Podiatric is a field ofhealthcare devoted to the study and treatmentof the lower extremities, most often the foot,ankle, knee, leg and hip.

Dental Malpractice - Neglect by a dental careprovider that causes injury.

Other Professional Malpractice - Neglect bysomeone that represents themselves ashaving more than average skills and abilitiesbut is not a heath or dental care professional,such as a lawyer or accountant.

Motor Vehicle - Injury or damages that mayoccur as the result of the negligent operationof a motor vehicle.

Products Liability - The area of law that holdsmanufacturers, distributors, suppliers,retailers and others who make productsavailable to the public responsible for injuriesthose products cause.

Environmental - The protection of nature fromthe impact of negligent human activities. Forexample, disposing of toxic chemicals thatresulted in pollution of a river or stream.

Asbestos - Injury or illness from exposure toasbestos.

Breast Implant - Injury or illness due to abreast implant.

Other Negligence - When the conduct ofsomeone is below the standard set by law inorder to protect others against unreasonablerisk of harm. This conduct results in injury,illness or damage and doesn't fall into theother tort categories listed above.

Other Tort (including intentional) - Anintentional act that someone should know cancause harm and does cause harm. This canbe assault, battery and false imprisonment. Itcan also be against someone's property suchas trespassing or unlawfully taking someonesproperty.

Special Proceedings: An action against a government office or agency.

Art. 75 (Arbitration) - To see if a dispute canbe resolved without going to trial. Arbitrationis a hearing in front of a person or panel ofpeople who are not judges. The parties in thecase may agree to arbitration or it may berequired by a section in a contract or by law.

Art. 77 (Trusts) - To enforce or decide anissue involving a trust, which is the legalholding and managing of money or propertybelonging to someone else.

Art. 78 - To review an administrative decisionby a governmental official or agency.

Election Law - This involves issues related toelections including who can vote, proceduresfor registering to vote, who can hold office,rules for placing questions on the ballot, howcandidates are selected, how elections arefinanced and the requirements for creatingdistricts.

Guardianship (MHL Art 81) - Appointing aguardian to handle the personal needs ormanage property for someone with mentaldisabilities.

Other Mental Hygiene - Any action involvingMental Hygiene laws that doesn't come underthe above. This can include admission,retention and/or transfer of a mentallydisabled person into the care of an inpatientand community based treatment facility.

Other Special Proceedings - Any actionagainst a government office or agency thatdoesn't fall under the categories listed above.

File AttachmentExplanation-JI & Action.8-14-08.wpd.pdf

Text BoxFor help in completing this form, click on the yellow question marks for instructions. Click on the yellow push pin for a detailed explanation of the choices under Nature of Judicial Intervention and Nature of Action or Proceeding.

Check ''Yes'' or ''No'' for each of the following questions:Is this action/proceeding against aYES NOYESNO

Public Authority:Municipality:(Specify:(Specify: ))

YES NODoes this action/proceeding seek equitable relief?Does this action/proceeding seek recovery for personal injury?Does this action/proceeding seek recovery from property damage?

Pre-Note Time Frames:This applies to all cases except contested matrimonials and tax certiorari cases.

Estimate time period for case to be ready for trial from filing of RJI to filing of Note of Issue:

Standard: 9 - 12 months Complex: 13 - 15 monthsExpedited: 0 - 8 months

Contested Matrimonial Cases Only: (Check and give date)Yes - Date:NoHas summons been served?

Was a Notice of No Necessity filed? Yes - Date:No

ATTORNEY(S) FOR PLAINTIFF(S):

Self-Rep.* Address Phone #Name

ATTORNEY(S) FOR DEFENDANT(S):Self-Rep.* AddressName Phone #

* Self Represented: Parties representing themselves, without an attorney, should check the ''Self-Rep.'' box and enter theirname, address and phone # in the space provided above for attorneys.

INSURANCE CARRIERS:

RELATED CASES: (If None, write ''NONE'' below)Title Index # Court Nature of Relationship

I affirm under penalty of perjury that, to my knowledge, other than as noted above, there are and have been no related actionsor proceedings, nor has a Request for Judicial Intervention previously been filed in this action or proceeding.

Dated:Signature

Print or type name

Attorney for

Attach rider sheet if necessary to provide the required information.

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InstructionsIf your case is a special proceeding (against a government office or agency) and the Defendant is a municipality (city, town or village), check "Yes" and put the name of the municipality that you are suing in the space provided. Otherwise, check "No".

InstructionsIf your case is a special proceeding and the Defendant is a public authority (a national, state or local government agency such as the NYS Transit Authority), check "Yes" and put the name of the public authority that you are suing in the space provided. Otherwise, check "No".

InstructionsEquitable relief - check "Yes" if you are asking for something other than a money award or in addition to a money award. For example, you are asking the court to direct someone to do something (return a family heirloom) or to stop doing something.Personal injury - check "Yes" if you are suing for money because of a personal injury.Property damage - check "Yes" if you are suing because your property was damaged or destroyed.

InstructionsCheck the box that best reflects how long it will take before you are ready to go to trial. If your case is a contested matrimonial or a tax certiorari, you don't have to answer this question. Put "NA" or "Not Applicable."

InstructionsIf your case is not a contested matrimonial, you don't have to answer these questions. Put "NA" or "Not Applicable".

If your case is a contested matrimonial and the Defendant (your spouse) has been served with a Summons, check "Yes" and put the date he/she was served. Otherwise, check "No".

If your case is a contested matrimonial and a Notice of No Necessity was filed, check "Yes" and put the date it was filed. A Notice of No Necessity is a written notice signed by both parties that states they agree that an RJI may be filed within 120 days instead of 45 days. Otherwise, check "No".

InstructionsAs you are representing yourself, check the box and put your full name, mailing address and phone number in the correct spaces.

InstructionsIf you know who Defendant's lawyer is, put the lawyer's name, business address and phone number in the spaces provided. If Defendant doesn't have a lawyer and will be representing him/herself, check the box and put Defendant's full name, mailing address and phone number in the spaces provided. If you don't know who will be representing Defendant, leave this section blank.

InstructionsIf you know of any insurance company that may provide coverage for the incident you are suing for (particularly where the company was given notice that there may be a claim), put the name of the insurance company. For example, if your case involves a car accident and your insurance company and the Defendant's insurance company are involved, put the names of those insurance companies. Otherwise, put "NA" or "Not Applicable."

InstructionsIf there are other cases that may have something to do with this action, put the information about the other cases in the spaces provided. If not, put "None." An example would be if you are suing about a car accident and there is another case involving a different Defendant because of the same accident. Under the heading "Nature of Relationship" you would put how or why the cases are connected.

InstructionsPut the date you complete the form.

InstructionsSign your name and print your name where indicated.

Court: County: FillText1: FillText2: PLAINTIFFS: Bill_of_Particulars_served: FillText15: YesNo_BOP: Request_for_Preliminary_Conference: Note_of_Issue_andor_Certificate_of_Readiness: Notice_of_Motion_return_date: FillText16: Relief_sought1: Order_to_Show_Cause: Relief_sought2: Other_Ex_Parte_Application_Specify1: Other_Ex_Parte_Application_Specify: Notice_of_Petition_return_date1: FillText17: Relief_sought: Notice_of_Medical_or_Dental_Malpractice_Action: Specify: Statement_of_Net_Worth: Writ_of_Habeas_Corpus: Other_Specify1: Other_Specify: Matrimonial: Commercial: FillText5: Real_Property: FillText8: CheckBox1: FillText9: MedicalPodiatric_Malpractice: Dental_Malpractice: Other_Professional_Malpractice: FillText3: Motor_Vehicle: Products_Liability: FillText4: Environmental: Asbestos: Breast_Implant: Other_Negligence: FillText6: Other_Tort_including_intentional: FillText7: Special_Proceedings: YesNo_Municipality: Specify2: YesNo_Authority: Specify1: YesNo_Equitable_Relief: YesNo_Personal_Injury: YesNo_Property_Damage: Time_Period_for_Trial: YesNo_Matrimonial_1: FillText18: YesNo_Matrimonial_2: FillText19: CheckBox7: Name1: Address1: PhoneNumber: PhoneNumber1: PhoneNumber2: CheckBox8: Name2: Address2: Comb1: Comb11: Comb2: CheckBox9: Name3: Address3: Comb21: Comb3: Comb4: CheckBox10: Name4: Address4: Comb31: Comb5: Comb6: FillText10: FillText11: FillText12: FillText13: FillText14: FillText20: Print_or_type_name: Attorney_for: