REQUEST FOR JUDICIAL INTERVENTION UCS-840

1 For Court Clerk Use Only: REQUEST FOR JUDICIAL INTERVENTIONIAS Entry Date(7/2012) UCS-840 COUNTY OF_____COURT,Judge AssignedDate Index Issued:_____Index No: _____RJI Dateattach a caption rider the complete case caption. Do not use et al or et ano. If more space is required,CAPTION:Plaintiff(s)/Petitioner (s)-against-Defendant(s)/Respondent(s)Ch eck ONE box only and specify where OF ACTION OR PROCEEDING:COMMERCIALMATRIMONIALG Business Entity (including corporations, partnerships, LLCs, etc.)G ContestedG ContractNOTE: For all Matrimonial actions where the parties have children underG Insurance (where insurer is a party, except arbitration)the age of 18, complete and attach the MATRIMONIAL RJI UCC (including sales, negotiable instruments)For Uncontested Matrimonial actions, use RJI form Other Commercial:_____TORTS(specify)G AsbestosNOTE: For Commercial Division assignment requests [22 NYCRR 'G Breast (d)], complete and attach the COMMERCIAL DIV RJI Environmental: _____REAL PROPERTY: How many properties does the application include?

2 _____(specify)G CondemnationG Medical, Dental, or Podiatric MalpracticeG ResidentialG Mortgage Foreclosure (specify):G Motor VehicleProperty Address: _____G Products Liability:_____(specify)NOTE: For Mortgage Foreclosure actions involving a one- to four-family,G Other Negligence:_____owner-occupied, residential property, or an owner-occupied(specify)condominium, complete and attach the FORECLOSURE RJI Other Professional Malpractice:_____G Tax Certiorari - Section: _____ Block: _____ Lot: _____(specify)G Tax ForeclosureG Other Tort:_____G Other Real Property:_____(specify)(specify)OTHER MATTERSSPECIAL PROCEEDINGSG Certificate of Incorporation/Dissolution [see NOTE under Commercial]G CPLR Article 75 (Arbitration) [see NOTE under Commercial]G Emergency Medical TreatmentG CPLR Article 78 (Body or Officer)G Habeas CorpusG Election LawG Local Court AppealG MHL Article (Kendra's Law)G Mechanic's LienG MHL Article 10 (Sex Offender Confinement-Initial)G Name ChangeG MHL Article 10 (Sex Offender Confinement-Review)G Pistol Permit Revocation HearingG MHL Article 81 (Guardianship)G Sale or Finance of Religious/Not-for-Profit PropertyG Other Mental Hygiene:_____G Other:_____(specify)(specify)G Other Special Proceeding:_____(specify)(specify)Answer YES or NO for EVERY question AND enter additional information where OF ACTION OR PROCEEDING:If yes, date filed: _____Has a summons and complaint or summons w/notice been filed?

3 If yes, date served: _____Has a summons and complaint or summons w/notice been served?If yes, judgment date: _____Is this action/proceeding being filed post-judgment?G CommercialState ZipCityStreet AddressNOYESGGGGGGC heck ONE box only AND enter additional information where OF JUDICIAL INTERVENTION :Infant's CompromiseNote of Issue and/or Certificate of ReadinessDate Issue Joined: _____Notice of Medical, Dental, or Podiatric MalpracticeReturn Date: _____Relief Sought: _____Notice of MotionReturn Date: _____Relief Sought: _____Notice of PetitionReturn Date: _____Relief Sought: _____Order to Show CauseRelief Sought: _____Other Ex Parte ApplicationPoor Person ApplicationRequest for Preliminary ConferenceResidential Mortgage Foreclosure Settlement ConferenceWrit of Habeas CorpusOther (specify): _____List any related actions. For Matrimonial actions, include any related criminal and/or Family Court CASES:If additional space is required, complete and attach the RJI Addendum.

4 If none, leave to Instant CaseJudge (if assigned)CourtIndex/Case TitleFor parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in space :If additional space is required, complete and attach the RJI (s):Insurance(Y/N):JoinedIssueAttorneys and/or Unrepresented Litigants:Parties: RepUn-litigants, provide address, phone number and e-mail of all attorneys that have appeared in the case. For unrepresentedProvide attorney name, firm name, business address, phone number and e-mail3rd-party plaintiff).indicate party role(s) ( defendant;List parties in caption order andG YESF irst NameLast NameLast NameGFirm NameFirst NameG NOCityStreet AddressPrimary Role:e-mailFaxPhoneSecondary Role (if any):G YESF irst NameLast NameLast NameGFirm NameFirst NameG NOCityStreet AddressPrimary Role:e-mailFaxPhoneSecondary Role (if any):G YESF irst NameLast NameLast NameGFirm NameFirst NameG NOCityStreet AddressPrimary Role:e-mailFaxPhoneSecondary Role (if any):G YESF irst NameLast NameLast NameGFirm NameFirst NameG NOCityStreet AddressPrimary Role:e-mailFaxPhoneSecondary Role (if any):THIS ACTION OR NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION PREVIOUSLY BEEN FILED INI AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS NOTED ABOVE, THERE ARE AND HAVE_____Dated: _____SIGNATURE_____PRINT OR TYPE NAMEATTORNEY REGISTRATION NUMBERGGGGGGGGGGGGZipStateZipStateZipSta teZipStat