Free How to Ask the Court to Change your Name (Adult) - New Jersey

Updated August 2008

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Revised 08/2008, CN 10551-English (How to Ask the Court to Change Your Name - Adult)

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HOW TO ASK THE COURT TO CHANGE YOUR NAME
(Superior Court of New Jersey - Law Division - Civil Part)

WHO SHOULD USE THIS PACKET?
You ca n use th is packet to a sk for a court order to c hange your name. T here is a nother pa cket f or information on changing the name of your chil d under the age of 18. Please note that, if you are a divorced woman s eeking to resu me using a na me y ou used before y our marriage or to assu me a new surname, y ou may want to contact the Family Division in the count y in w hich your judgment of divorce was entered. However, you are not precluded from using this packet. Note: Do not use this packet if you want to correct a m istake on a birth certificate or m arriage license (for exam ple, incorrect or m isspelled nam e or misstatement of gen der). You should contact the State Registrar of Vital Statistics directly regarding these changes.

Note: These materials have been prepared by the New Jersey Administrative Office of the Courts for use by self-represented litigants. The guides, instructions, and forms will be periodically updated as necessary to reflect current New Jersey statutes and court rules. The most recent version of the forms will be available at the county courthouse or on the Judiciary's Internet site www.njcourtsonline.com. However, you are ultimately responsible for the content of your court papers.

Completed forms are to be submitted to the county where you are filing your case. A list of Superior Court Offices is provided at the customer counter or at www.njcourtsonline.com.

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Name Change - Adult

THINGS TO THINK ABOUT BEFORE YOU TRY TO REPRESENT YOURSELF IN COURT

TRY TO GET A LAWYER The court s ystem can be confusing an d it is a good idea to get a lawy er if you can. The law, the proofs neces sary to present y our c ase, an d the procedural rules governing cases in the Law Division, Civil Part are complex. Since valuable claims or potentially heavy judgments may be at stake, most litigants appearing in the Law Division, Civ il Part have a lawy er. If you are being sued, please co ntact y our insurance company to see if they might provide a la wyer for you. M ost likely your opponent will b e represented by a lawyer. It is reco mmended that you make every effort to obtain the assistance of a lawy er. If you cannot afford a lawy er, you may contact the legal ser vices program in y our county to see if y ou qualify for fr ee legal services. Their telephone num ber can be found in your local yellow pages under "Legal Aid" or "Legal Services." If you do not qualify for free legal serv ices and need help in locating an attorney, you can contact the bar association in your county. That number can also be found in your local y ellow pages. Most count y bar associations have a Lawyer Referral Service. The County Bar Lawyer Referral Service can supply you with the names of attorneys in your area willing to handle your particular ty pe of case and will sometimes consult with you at a reduced fee. There are also organizations of minority lawy ers through out New Jersey, as well a s organizations of lawy ers who handle specialized types of case s. Ask your county court staff for a list of lawy er referral services that include these organizations. If you decide to proceed without an attorney, these materials explain the procedures that m ust be followed t o have your papers prope rly filed and considered by the court. These materials do not provi de inform ation o n the law governing your claims or defenses; i nformation o n how to conduct pretrial discovery ; inform ation on alternative di spute resolution procedures, such as arbitration or mediation, that may be available or required in your case; inform ation on the

kinds of evidence you need to prove your claims or defense at trial; or information on ot her procedural and evidentiary rules governing civil law suits. WHAT YOU SHOULD EXPECT IF YOU REPRESENT YOURSELF While you have the right to represent y ourself in court, you sh ould not exp ect special treatment, help or attention from the court. The following is a list of so me things court staff can an d cannot do for you. Please read it carefully before asking court staff for help.

- We can explain and answer questions about - We can tell you what the requirements are to - - - - - - - - - - -
how the court works. have your case considered by the court. We can give you som e inform ation from your case file. We can provide you with sam ples of court forms that are available. We can provide you with guidance on how to fill out forms. We can usually answer questions about court deadlines. We cannot give you legal advice. Only your lawyer can give you legal advice. We cannot t ell you whether or n ot you should bring your case to court. We cannot give you an op inion abo ut what will happen if you bring your case to court. We cannot recommend a lawyer, but we can provide you with the telep hone number of a local lawyer referral service. We cannot t alk to t he ju dge for you about what will happen in your case. We cannot let you talk to the judge out side of court. We cannot change an o rder issued b y a judge.

KEEP COPIES OF ALL PAPERS Make and keep copies of all co mpleted forms and documents related to y our case.

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Name Change - Adult

OVERVIEW The following is a brief o verview of the process for having your name changed by a court. The details follow. There are three basic steps that you must take to have your name changed by the court: 1. You m ust fill out form s to send to t he court with a filing fee. (I f you are ch anging t he n ames o f multiple family members, there is only one fee.) The forms are contained in this packet and include a complaint, an order fixing the date of hearing, a final judgment and a case information statement. 2. When the court returns the co mplaint and the order fixing the dat e of hearing to you, the fo rms will contain a docket num ber and will tell you in what news paper you must publish the date of hearing. You must contact the newspaper to have the order fixing the date for the hearing pu blished at least two weeks before the hearing date, and you m ust n otify other in terested parties. You will have to provide the court with pro of that the appropriate pa rties have been notified of your intent to change your name. 3. After you appear in court at the hearing, you will have to publish the final judgment in the newspaper. You will also have to send copies of the certified final judgment to the Department of Treasury and the Registrar of Vital Statistics. If you have a driver's license, you will have to present a copy of the certified final judgment in person to the Motor Vehicle Commission. DEFINITIONS OF WORDS USED IN THIS PACKET Affidavit of Publication - An affidavit of publ ication is a sw orn statement made by a n ewspaper stating that the newspaper has published the information regarding your name change. Certification - A certification is a written statement you make when you file your papers with the court in which you state that all the information contained in the papers is true to the best of your knowledge. Civil Case Information Statement (CIS) The CIS is a for m that summari zes your case for the court. Court rules require that a CIS be filed with a verified complaint. Docket Number - A docket nu mber is the num ber t he court assi gns to your case so that it may be identified and located easily . Once you have a doc ket num ber, you m ust include it on all y our communications with the court. File - To file means to give the appropriate forms and fee to the court to begin the court's consideration of your case. Final Judgment - The final judgment is a docu ment signed by the judge which orders the nam e to be changed. Order Fixing Date of Hearing - An order fixing the date of hearing is a signed paper fro m the judge indicating the date when you must come to court on your case and stating the name of the newspaper in which you will have to publish your hearing date. Proof of Mailing - Proof of mailing is the green card you get back from the Post Office that proves that the material you sent by certified mail, return recei pt requested, was received by the person to whom you sent it. Verified Complaint - A verified complaint is a do cument in which you tell the court the facts of y our case and state what relief you want the court to give you. You certify that the information is true to the best of your knowledge.

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Name Change - Adult

The numbered steps listed below tell you what forms you will need to fill out and what to do with them. Each form should be typed or printed clearly on 8 ½ "x 11" white paper only. Forms may not be filed on a different size or color paper. STEPS TO OBTAIN A COURT ORDER TO CHANGE YOUR NAME STEP 1: FILL OUT THE VERIFIED COMPLAINT (Form A). The Verified Complaint (Form A) tell s the court what your nam e is, what y ou want to change it to, and wh y you want it ch anged. If you have ever been convicted of a crime, or if there are charges pending against you, you must include this inform ation in your Verified Complaint. You must sign the cert ification which states that the inform ation in the complaint is true to the best of your knowledge. STEP 2: FILL OUT THE ORDER FIXING DATE OF HEARING AND THE FINAL JUDGMENT FORMS (Forms B and C). Enter the inf ormation requested. Note that there are pla ces on the Order Fixing Date of Hearing and Final Judgment that the court will complete. STEP 3: FILL OUT THE CIVIL CASE INFORMATION STATEMENT (CIS) (Form F). This form s ummarizes y our case for the court. The case ty pe number for a name change is 151. STEP 4: MAKE A CHECK OR MONEY ORDER PAYABLE TO TREASURER, STATE OF NEW JERSEY IN THE AMOUNT OF $200.00. This is the fee for filing your papers. Note: If you are changing the names of multiple family members, the $200.00 fee covers all name change applications. Check y our forms and make sure the y are complete. Re move all instruction sheets. Make sure y ou ha ve signed all the form s wherever necessary. You also need to make two copies of each for m. One copy will be sent to t he court; the other is for your records. Checklist - In Step 6 you will be directed to mail your documents to the court. The following checklist wi ll help insure y our package is complete: - The original of each of th e forms you filled out: Verified Complaint (Form A), Order Fixing Date of Hearing (Form B), Final Judgment (Form C) and the Civil Case Information Statement (Form F) - One copy of each of these forms: Verified Complaint, Order Fixing Date of Hearing, Final Judgment and the Civil Case Information Statement. - The filing fee in the amount of $200. It must be a check o r money ord er pay able to the Treasurer, State of New Jersey. - A sta mped e nvelope addressed to yourself so that the court will be able to return the forms to you. Be sure to include adequate postage. STEP 6: MAIL OR DELIVER THE FORMS TO THE COURT. You may mail or deliver to the court the original and one cop y of all the forms: Verified Complaint (Form A), Order Fixing Date of Hearing(Form B), Final Judgment (Form C) and the Civil Case Information Statement (Form F) along with a self-addresse d stam ped envelope and the fi ling fee. The court address can be foun d on the J udiciary's website, www.njcourtsonline.com. If you m ail the papers, we r ecommend that you use certified mail, return receipt requested.

STEP 5: CHECK COMPLETED FORMS COPIES.

AND

YOUR MAKE

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Name Change - Adult

STEP 7: REVIEW COPIES RETURNED FROM COURT. The court will return copies of the Verified Complaint and Order Fixing Date of Hearing to you. Once you receive t hem, there will be a docket number written on all the co pies. The docket number is very i mportant because it identifies your case. It al so lets the court know how to find your case. You must use the docket number on all future papers you send to the court about your case. The court will fill in the date on t he Order Fixing Date of Hearing. That is the day you will appear before the judge to get the final judgment. The court will also indicate the nam e of a newspaper in which you are to have the notice of your hearing date published. IF YOU DO NOT HAVE PENDING CRIMINAL OR DELINQUENT CHARGES IN NEW JERSEY, SKIP TO STEP 9.

You m ust have the Order Fixing Date of Hearing published in the newspaper th e judge chooses. It must be publis hed in the ne wspaper at least two (2) weeks before the date of the hearing. You should talk to the newspaper about how to publi sh legal notices. Included in this packet as A ttachment E is a sample of the newspaper notice. STEP 10: SEND AFFIDAVIT OF PUBLICATION TO THE COURT. Once y ou have published the Order Fixing Date of Hearing, the newspaper will send you an affidavit of publication, which is proof that you had the newspaper publi sh the Order Fixing Date of Hearing. You m ust send the original of this affidavit of publication document to the court immed iately after you get it f rom the newspaper. Keep a copy of it for your files. IF YOU HAVE MAILED COPIES TO THE COUNTY PROSECUTOR OR THE ATTORNEY GENERAL, COMPLETE STEP 11.

STEP 8: NOTIFY THE STATE OR COUNTY PROSECUTOR OF YOUR APPLICATION FOR A NAME CHANGE. If you have criminal charges pending against you in New Jerse y, you m ust send a copy of the Verified Complaint and Order Fixing Date of Hearing by certified mail, return receipt requested to th e Prosec utor of the county where the matter is being heard. If the charges were brought b y th e O ffice o f the Attorney General, you must sen d another copy of t he Verified Complaint and Order Fixing Date of Hearing by c ertified m ail, ret urn receipt requested to the Director of the Division of Criminal Justice in Tr enton, New Jersey, at least 20 days before the hearing. Ma il a copy to: Director of Criminal Justice R. J. Hughes Justice Complex 25 W. Market Street P. O. Box 085 Trenton, NJ 08625-0085

STEP 11: COMPLETE PROOF OF MAILING (FORM D) AND SEND TO COURT. After you have mailed the required copies of the Verified Complaint and signed Order Fixing Date for Hearing, the post office will send you a green card (c alled a c ertified mail receipt) that shows the mail was deliv ered. Once y ou get it back, fill out the form called Proof of Mailing (Form D) and check each entity to whom y ou sent a copy of the co mplaint and order. Be sure to attach the original green certifi ed mail receipt(s) to t he original proof of m ailing. Send the proof of mailing to the court. Keep a copy of it for your files. STEP 12: APPEAR IN COURT ON THE DATE SET BY THE JUDGE FOR YOUR HEARING.

STEP 9: PUBLISH THE ORDER FIXING DATE OF HEARING. In the Order Fixing Date of Hearing that you receive back fro m th e court, the j udge will have specified the nam e of a local newspaper.

STEP 13: PUBLISH THE FINAL JUDGMENT IN THE NEWSPAPER. After the hearing, t he court will record the original Final Judgment signed by the judge. As
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Revised 08/2008, CN 10551-English (How to Ask the Court to Change Your Name - Adult)

Name Change - Adult

soon as you receive y our copy of the Final Judgment, you m ust send it to be publi shed in the newspap er chosen by the judge. However, the newspap er published version of the final judgment shall not i nclude your social security number. The Final Judgment must appear in the newspaper no more than 20 days after the date on the j udgment. After you have it published, the newspaper will send you an original affidavit of publication.

STEP 14: SEND THE AFFIDAVIT OF PUBLICATION TO THE COURT. As soon as you receive the Affidavit of Publication from the n ewspaper, send the original to t he Court as proof that you had the newspaper publish the Final Judgment. Keep a copy for your records. STEP 15: ORDER A CERTIFIED COPY OF FINAL JUDGMENT. You m ust order from the court a certified copy of the Final Judgment, by m ail or in person. There is no charge for the first certified copy. Additional copies can be ordered for $5.00 each. Keep t his for your files. Copies of the certified Final Judgment must be sent to the Department of Treasury (Step 16), the Registrar of Vital Stat istics (Step 17), and pre sented in person at an y Motor Vehicle Ag ency or Regional Service Center (Step 18). STEP 16: SEND COPY OF CERTIFIED FINAL JUDGMENT TO THE DEPARTMENT OF TREASURY. Mail a copy of the certified Final Judgment to the Depart ment of Treasury within 45 days after the date of the Judgment. You must include a check or money order pay able to the Treasurer, State of New Jersey in the am ount of $50. Mail the copy of the certified Final Judgment with the check or m oney or der and a stamped self-addressed envelope to: Department of Treasury Division of Revenue Judgment Name Change Unit P. O. Box 453 Trenton, NJ 08646

STEP 17: NOTIFY THE REGISTRAR OF VITAL STATISTICS OF THE STATE. You should send a copy of the certified Final Judgment to the Registrar of Vital Statistics of the State in which you w ere born. You can loc ate the address of that office by contacting them by telephone. Directory assistance can provide you with the t elephone number of th at office. Th ey are locate d in the capital city of the State in which your were born. That office will tell you if there is a fili ng fee. If you were born in New Jersey , the address for this office is: Bureau of Vital Statistics P. O. Box 370 Trenton, NJ 08625 In New Jersey there is also a $27. 00 f ee if you want to receive a corrected birth certificate. STEP 18: NOTIFY THE MOTOR VEHICLES COMMISSION . If y ou are a licensed dri ver, a regist ered owner of a vehicle, or posses ses a han dicapped or no n-driver identification card, you m ust present the Final Judgment in person at any Motor Vehicle Agency or Regional Service Center within two weeks of the date of the Final Judgment. Additional information is available at the MVC web site at www.njmvc.gov regarding the list of acceptable documents to satisfy the 6 points of identification.

++++++

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Print All Forms

Clear All Forms

FORM A SUPERIOR COURT OF NEW JERSEY LAW DIVISION
County
Your Name (first, middle, last)

Docket Number
Street Address Town, State, Zip Code

(to be filled in by the court)

Telephone Number

CIVIL ACTION

In the Matter of the Application of
Your Name (first, middle, last)

Verified Complaint Including Certification of Plaintiff

To Assume the Name of
Name You Wish To Assume (first, middle, last)

for Name Change

The plaintiff,

(your name, first, middle, last)

, whose place of residence is

(street address)

, in the City of

County of 1. I am the Plaintiff in this matter. 2. I am (check one) am

, in the State of New Jersey, says:

am not a citizen of the United States of America.
, in . . and
(place of birth)

3. My social security number is 4. I was born on
(month, day, year)

5. I am the (check one) son 6. I was raised by

daughter of
.

and

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FORM A
7. I have since birth been identified by the following names:
(first, middle, last) ..

8. I (check one) have

have never been married.

9. I have no unsatisfied judgments of record, or suits pending against me, except:

(enter any recorded judgments or pending suits)

10. I have never been convicted of a crime, and have no criminal charges pending against me, except:

(please supply county, municipality, nature, date of crime and/or pending charges)

11. This application is not being made with the intent to avoid creditors or criminal prosecution or for other fraudulent purpose.

12. I (check one) have

have not made any previous applications to assume another name.
(first, middle, last)

13. I desire to assume the name of:

.

14. I request this name change for the following reasons:

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FORM A

WHEREFORE, plaintiff demands judgment pursuant to N.J.S.A. 2A:52-1 to -4.

Signature of Plaintiff

Certification
I certify that the foregoing statements are true. I am aware that if any of the foregoing statements made by me are wilfully false, I am subject to punishment.

Signature of Plaintiff

Dated:

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FORM B SUPERIOR COURT OF NEW JERSEY LAW DIVISION
County
Your Name (first, middle, last) Street Address Town, State, Zip Code

Docket Number

(to be filled in by the court)

Telephone Number

In the Matter of the Application of
Your Name (first, middle, last)

CIVIL ACTION

To Assume the Name of
Order Fixing Date
Name You Wish To Assume (first, middle, last)

Of Hearing

Application being made to the Court by for a judgment authorizing (check one)

(your name, first, middle, last)

,

his her to assume another name and for

the entry of an order fixing a date for the hearing of such application, DO NOT WRITE BELOW; THE COURT WILL FILL IN THE INFORMATION IT IS ON THIS the of day of , County of day of , 20 , 20 , at , State of New Jersey, be , ORDERED that

a.m., or as soon thereafter as the matter can be heard, at the Court House in the City fixed as the time and place for the hearing of such application and of any objections that may be made thereto.

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FORM B
IT IS FURTHER ORDERED that a notice of such application be published in once, at least two (2) weeks preceding the date set for the hearing.

J.S.C.

,

NOTE: Copies of the verified complaint and order fixing the date of the hearing must be sent to the newspaper for publication and served on the County Prosecutor and/or the Office of the Attorney General if there are criminal charges pending.

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FORM C SUPERIOR COURT OF NEW JERSEY LAW DIVISION
Your Name (first, middle, last)

County Docket Number
(to be filled in by the court)

Street Address Town, State, Zip Code

Telephone Number

In the Matter of the Application of
Your Name (first, middle, last)

CIVIL ACTION

To Assume the Name of
Name You Wish To Assume (first, middle, last)

Final Judgment

(your name, first, middle, last)

, having made application to this Court

by duly verified complaint for a judgment authorizing (check one) him her to , and it appearing to assume the name of
(name you wish to assume)





the Court that all the provisions of N.J.S.A. 2A:52-1-4 and the Current N.J. Court Rules relating thereto have been complied with: IT IS on this day of ,20 , , who , from

(leave date blank for court to complete)

ORDERED AND ADJUDGED that was born on

(your name)

(month, day, year )

, and whose social security number is

(your social security number)

be and hereby is authorized to assume the name of and after ; and

(name you wish to assume)

(leave date blank for court to complete)

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DO NOT WRITE BELOW THIS LINE; THE COURT WILL COMPLETE. IT IS FURTHER ORDERED that within twenty days hereof plaintiff shall cause a copy of this Final Judgment to be published once in____________________________; and within forty-five days after entry of Judgment, plaintiff shall file proof of publication of this Final Judgment with the deputy Clerk of the Superior Court (in which you filed your verified complaint) and a certified copy of this Final Judgment with the Department of Treasury pursuant to the provisions of the Statute and Rules in such case made and provided; and IT IS FURTHER ORDERED that the published version of the final judgment shall not contain the social security number of the person whose name was changed.

J.S.C.

Dated:

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FORM D SUPERIOR COURT OF NEW JERSEY LAW DIVISION
County
Your Name (first, middle, last)

Docket Number
(to be filled in by the court) Street Address Town, State, Zip Code

Telephone Number

CIVIL ACTION
In the Matter of the Application of
Your Name (first, middle, last)

To Assume the Name of
Name You Wish To Assume (first, middle, last)

Proof of Mailing

On

, I, the undersigned, mailed a copy of the Complaint for

Change of Name and Order Fixing Date of Hearing in accordance with the rules of Civil Practice and Procedure, by certified United States Mail, return receipt requested to (check and complete all that apply): __ the Division of Criminal Justice of New Jersey __ the Prosecutor of NOTE: The green return mail receipt(s) are attached. I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are wilfully false, I am subject to punishment. County

Your Signature

Dated:

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ATTACHMENT E

SAMPLE NEWSAPER NOTICE
IN THE MATTER OF THE APPLICATION OF
Your name (first, middle, last)

TO ASSUME THE NAME OF
Name you wish to assume (first, middle, last)

TO WHOM IT MAY CONCERN: Take notice that the undersigned will apply to
(county where name change action is filed)

County Superior Court on the
(name of city)

day of

20

, at ,

9 o'clock in the morning, at the Court House in the City of New Jersey, for a judgment authorizing __________________________ to assume the
(your name, first middle, last)

name of _________________________________________________.
(your name to assume, first, middle, last)

Your Name (first, middle, last)

Street Address

Town, State, Zip Code

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HOW TO COMPLETE THE CIVIL CASE INFORMATION STATEMENT (CIS)
These instructions are intended to guide individuals who are either plaintiffs or defendants in civil cases and who are not represented by an attorney in completing the Civil Case Information Statement (Civil CIS) required by court rules. The Civil CI S must be included with each party's first pleading in the Civil part of the Law Division. That is, th e plaintiff must file it with the complaint and the defendant must file it with the answer. If it is not included, the papers will be returned. The CIS summarizes your case and alerts the c ourt to any special needs you m ay have such as the need for an interpreter or the need for a quick trial date because one of your witnesses is expected to be unavailable. The numbers for the various case types are located on the back of the form. Enter the number which best describes your complaint. For example, if you are suing the defendant for a breach of contract, your case number would be 599. After you have completed the CIS, keep it with the other papers you are planning to file. Note: Thes e m aterials have been prepared b y the New Jersey Ad ministrative Office of the Courts for use by self-represented litigants. The guides, instructions, and forms will b e periodically updated as necessary to ref lect current New Jersey statutes and court ru les. The m ost recent version of the form s will be a vailable at the county courthouse or on th e Judiciary's Internet site (www.njcourtsonline.com). Howe ver, you are ultim ately responsible for the content of your court papers.

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INSTRUCTIONS FOR PARTIES NOT REPRESENTED BY AN ATTORNEY FOR COMPLETING THE CIVIL CASE INFORMATION STATEMENT (CIS)
BOX# INSTRUCTION 1. Print your name. 2. List a telephone number, including area code, where you can be reached during the day. 3. Insert the name of the county where the complaint or answer is being filed. 4. Leave the box blank. 5. If you know the docket number of your case, insert it in the docket number box. If the CIS is being filed with a complaint, the court will assign the docket number before it returns the filed complaint. 6. Enter an address where you wish to receive mail concerning this matter. 7. Document type means the type of paper you are filing. If you are filing the complaint, print complaint; if you are filing an answer, print answer. 8. Check the box marked "yes" if you have requested that the matter be heard by a jury. Otherwise, check "no." 9. Enter your name and indicate whether you are the plaintiff or defendant. 10. The caption is the name of the case - the name of the plaintiff(s) v. the name of the defendant(s). For example: John Doe, Plaintiff v. Mary Smith, Defendant. Print the name of your case. 11. The Case Type Number identifies the type of case. On the back of the CIS form is a list of case types. Sometimes it is difficult to pick the number of your case, but you must fill in this section in order for your case to proceed. Choose the one that best describes what your case is about and enter that number. For example, if you are the plaintiff or defendant in a dispute over fulfilling the terms of a contract, the case type is 599; if your case concerns a personal injury, the case type number is 605. 12. If you believe that your case is a professional malpractice case, check the box marked "yes" and see N.J.S.A. 2A:53A-27 and applicable case law regarding your obligation to file an affidavit of merit. 13. If you believe that you have any other cases involving the same adversary or arising from the same set of circumstances, check the box marked "yes." Otherwise, check "no." 14. If you checked "yes" to the previous question, enter the docket number(s) of any related cases. 15. If you believe you will be adding more parties to the case, check "yes." Otherwise, check "no." 16. If you are the plaintiff and know the name of the defendant's primary insurance company enter it in the box. Otherwise check "unknown." If you are the defendant and you have insurance that might cover or partially cover the damages complained of, enter the name of your insurance company.

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17.

If you and your adversary knew each other before the event giving rise to the law suit occurred, check "yes." Otherwise, check "no." If the answer was "yes", check the box next to the word(s) that best describe the relationship between the parties. If you believe that the statute governing your case provides for payment of fees by the losing party, (for example, the Law Against Discrimination), check "yes." Otherwise, check "no." If you believe that your case has some unusual circumstance which would require special attention, indicate the problem in the space provided. For example, if there is a witness who is ill or who may be unavailable, you should let the court staff know. If you are requesting any accommodation for a disability, check "yes" and indicate what is needed. Otherwise, check "no." If you are requesting an interpreter, check "yes" and indicate the language for which it is needed. Otherwise, check "no." The person whose name appears in Box 1 must sign the CIS in the space marked "Attorney Signature."

18. 19.

20. 21. 22.

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CIVIL CASE INFORMATION STATEMENT
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 if attorney's signature is not affixed.
1. ATTORNEY/PRO SE NAME 4. FIRM NAME (If applicable) 6. OFFICE ADDRESS 2. TELEPHONE NUMBER

FOR USE BY CLERK'S OFFICE ONLY

(CIS)

PAYMENT TYPE: CK CHG/CK NO. AMOUNT: OVERPAYMENT: BATCH NUMBER:

CG

CA

3. COUNTY OF VENUE 5. DOCKET NUMBER (When available) 7. DOCUMENT TYPE 8. JURY DEMAND

(

)

YES

NO

9. NAME OF PARTY (e.g., John Doe, Plaintiff)

10. CAPTION

11. CASE TYPE NUMBER (See reverse side for listing)

12. IS THIS A PROFESSIONAL MALPRACTICE CASE?

YES

NO

IF YOU HAVE CHECKED "YES," SEE N.J.S.A. 2A:53A-27 AND APPLICABLE CASE LAW REGARDING YOUR OBLIGATION TO FILE AN AFFIDAVIT OF MERIT.

13. RELATED CASES PENDING? YES NO 15. DO YOU ANTICIPATE ADDING ANY PARTIES (arising out of same transaction or occurrence)?

14. IF YES, LIST DOCKET NUMBERS 16. NAME OF DEFENDANT'S PRIMARY INSURANCE COMPANY, IF KNOWN NONE UNKNOWN

YES

NO

THE INFORMATION PROVIDED ON THIS FORM CANNOT BE INTRODUCED INTO EVIDENCE.
CASE CHARACTERISTICS FOR PURPOSES OF DETERMINING IF CASE IS APPROPRIATE FOR MEDIATION 17. A. DO PARTIES HAVE A CURRENT, PAST OR RECURRENT RELATIONSHIP? YES NO IF YES, IS THAT RELATIONSHIP EMPLOYER-EMPLOYEE FAMILIAL FRIEND/NEIGHBOR BUSINESS

OTHER (explain)

18. B. DOES THE STATUTE GOVERNING THIS YES NO CASE PROVIDE FOR PAYMENT OF FEES BY THE LOSING PARTY? 19. USE THIS SPACE TO ALERT THE COURT TO ANY SPECIAL CASE CHARACTERISTICS THAT MAY WARRANT INDIVIDUAL MANAGEMENT OR ACCELERATED DISPOSITION:

20. DO YOU OR YOUR CLIENT NEED ANYDISABILITY ACCOMMODATIONS? 21. WILL AN INTERPRETER BE NEEDED? 22. ATTORNEY SIGNATURE

YES

NO

IF YES, PLEASE IDENTIFY THE REQUESTED ACCOMMODATION:

YES

NO

IF YES, FOR WHAT LANGUAGE:

Revised 08/2008, CN 10551-English (How to Ask the Court to Change Your Name - Adult) Revised 03/2009, CN 10517-English

page 19 of 20

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
151 175 302 399 502 505 506 510 511 512 801 802 999 NAME CHANGE FORFEITURE TENANCY REAL PROPERTY (other than Tenancy, Contract, Condemnation, Complex Commercial or Construction) BOOK ACCOUNT (debt collection matters only) OTHER INSURANCE CLAIM (INCLUDING DECLARATORY JUDGMENT ACTIONS) PIP COVERAGE UM or UIM CLAIM ACTION ON NEGOTIABLE INSTRUMENT LEMON LAW SUMMARY ACTION OPEN PUBLIC RECORDS ACT (SUMMARY ACTION) OTHER (Briefly describe nature of action)

Track II -- 300 days' discovery
305 509 599 603 605 610 699 CONSTRUCTION EMPLOYMENT (other than CEPA or LAD) CONTRACT/COMMERCIAL TRANSACTION AUTO NEGLIGENCE ­ PERSONAL INJURY PERSONAL INJURY AUTO NEGLIGENCE ­ PROPERTY DAMAGE TORT ­ OTHER

Track III -- 450 days' discovery
005 301 602 604 606 607 608 609 616 617 618 620 CIVIL RIGHTS CONDEMNATION ASSAULT AND BATTERY MEDICAL MALPRACTICE PRODUCT LIABILITY PROFESSIONAL MALPRACTICE TOXIC TORT DEFAMATION WHISTLEBLOWER / CONSCIENTIOUS EMPLOYEE PROTECTION ACT (CEPA) CASES INVERSE CONDEMNATION LAW AGAINST DISCRIMINATION (LAD) CASES FALSE CLAIMS ACT

Track IV -- Active Case Management by Individual Judge / 450 days' discovery
156 280 303 508 513 514 701 ENVIRONMENTAL/ENVIRONMENTAL COVERAGE LITIGATION ZELNORM MT. LAUREL COMPLEX COMMERCIAL COMPLEX CONSTRUCTION INSURANCE FRAUD ACTIONS IN LIEU OF PREROGATIVE WRITS

Mass Tort (Track IV)
248 266 271 272 274 275 276 277 CIBA GEIGY HORMONE REPLACEMENT THERAPY (HRT) ACCUTANE BEXTRA/CELEBREX RISPERDAL/SEROQUEL/ZYPREXA ORTHO EVRA DEPO-PROVERA MAHWAH TOXIC DUMP SITE 278 279 281 282 283 284 601 619 ZOMETA/AREDIA GADOLINIUM BRISTOL-MYERS SQUIBB ENVIRONMENTAL FOSAMAX DIGITEK NUVARING ASBESTOS VIOXX

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:

Verbal Threshold

Putative Class Action

Title 59
page 20 of 20

Revised 08/2008, CN 10551-English (How to Ask the Court to Change Your Name - Adult) Revised 03/2009, CN 10517-English