For Court Clerk Use Only:REQUEST FOR JUDICIAL INTERVENTIONIAS Entry Date(3/2011)UCS-840

COUNTY OF_________________________________________________COURT,Judge Assigned

Date Index Issued:___________________Index No: _____________________

RJI Date

required, attach a caption rider sheet.Enter the complete case caption. Do not use et al or et ano. If more space isCAPTION:

Plaintiff(s)/Petitioner(s)

-against-

Defendant(s)/Respondent(s)

Check ONE box only and specify where indicated.NATURE OF ACTION OR PROCEEDING:

COMMERCIALMATRIMONIAL

G Business Entity (including corporations, partnerships, LLCs, etc.)G Contested

G ContractG Uncontested

G Insurance (where insurer is a party, except arbitration)NOTE: For all Matrimonial actions where the parties have children under

G UCC (including sales, negotiable instruments)the age of 18, complete and attach the MATRIMONIAL RJI Addendum.

G Other Commercial:______________________________________________TORTS(specify)G Asbestos

NOTE: For Commercial Division assignment requests [22 NYCRR 'G Breast Implant

202.70(d)], complete and attach the COMMERCIAL DIV RJI Addendum.G Environmental: _______________________________________________

REAL PROPERTY: How many properties does the application include? _________(specify)

G CondemnationG Medical, Dental, or Podiatric Malpractice

G ForeclosureG Motor Vehicle

Property Address: ________________________________________________G Products Liability:_______________________________________________(specify)

NOTE: For Foreclosure actions involving a one- to four-family, owner-G Other Negligence:_______________________________________________

occupied, residential property, or an owner-occupied condominium,(specify)

complete and attach the FORECLOSURE RJI Addendum.G Other Professional Malpractice:____________________________________

G Tax Certiorari - Section: __________ Block: __________ Lot: __________(specify)

G Other Real Property:_____________________________________________G Other Tort:____________________________________________________(specify)(specify)

SPECIAL PROCEEDINGSOTHER MATTERS

G CPLR Article 75 (Arbitration) [see NOTE under Commercial]G Certificate of Incorporation/Dissolution [see NOTE under Commercial]

G CPLR Article 78 (Body or Officer)G Emergency Medical Treatment

G Election LawG Habeas Corpus

G MHL Article 9.60 (Kendra's Law)G Local Court Appeal

G MHL Article 10 (Sex Offender Confinement-Initial)G Mechanic's Lien

G MHL Article 10 (Sex Offender Confinement-Review)G Name Change

G MHL Article 81 (Guardianship)G Pistol Permit Revocation Hearing

G Other Mental Hygiene:___________________________________________G Sale or Finance of Religious/Not-for-Profit Property(specify)G Other:________________________________________________________

G Other Special Proceeding:________________________________________(specify)

(specify)

Answer YES or NO for EVERY question AND enter additional information where indicated.STATUS OF ACTION OR PROCEEDING:

If yes, date filed: _____________________________Has a summons and complaint or summons w/notice been filed?

If yes, judgment date: _____________________________Is this action/proceeding being filed post-judgment?

State ZipCityStreet Address

NOYES

GGGG

Supreme

SAMPLE

Albany

John Doe

600 East Broadway

Syracuse, New York 12206

Check ONE box only AND enter additional information where indicated.NATURE OF JUDICIAL INTERVENTION:Infant's Compromise

Note of Issue and/or Certificate of Readiness

Date Issue Joined: _____________________________Notice of Medical, Dental, or Podiatric Malpractice

Return Date: _____________________________Relief Sought: _________________________Notice of Motion

Return Date: _____________________________Relief Sought: _________________________Notice of Petition

Return Date: _____________________________Relief Sought: _________________________Order to Show Cause

Relief Sought: _________________________Other Ex Parte Application

Poor Person Application

Request for Preliminary Conference

Residential Mortgage Foreclosure Settlement Conference

Writ of Habeas Corpus

Other (specify): ___________________________________________________________________________________________________

List any related actions. For Matrimonial actions, include any related criminal and/or Family Court cases.RELATED CASES:

If additional space is required, complete and attach the RJI Addendum. If none, leave blank.

Relationship to Instant CaseJudge (if assigned)CourtIndex/Case No.Case Title

If additional space is required, complete and attach the RJI Addendum.PARTIES:

For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in "Attorneys" space.

Insurance Carrier(s):

(Y/N):

Joined

IssueAttorneys:Parties:

Rep

Un-

address of all attorneys that have appeared in the case.Provide name, firm name, business address, phone number and e-mail

3rd-party plaintiff).indicate party role(s) (e.g. defendant;List parties in caption order and

G YESFirst NameLast NameLast Name

G Firm NameFirst Name

G NOCityStreet Address

Primary Role:

e-mailFaxPhone

Secondary Role (if any):

G YESFirst NameLast NameLast Name

G Firm NameFirst Name

G NOCityStreet Address

Primary Role:

e-mailFaxPhone

Secondary Role (if any):

G YESFirst NameLast NameLast Name

G Firm NameFirst Name

G NOCityStreet Address

Primary Role:

e-mailFaxPhone

Secondary Role (if any):

G YESFirst NameLast NameLast Name

G Firm NameFirst Name

G NOCityStreet Address

Primary Role:

e-mailFaxPhone

Secondary Role (if any):

FILED IN THIS ACTION OR PROCEEDING.

HAVE BEEN NO RELATED ACTIONS OR PROCEEDINGS, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION PREVIOUSLY BEEN

I AFFIRM UNDER THE PENALTY OF PERJURY THAT, TO MY KNOWLEDGE, OTHER THAN AS NOTED ABOVE, THERE ARE AND

________________________________________________Dated: _____________________________SIGNATURE

________________________________________________________________________________________________PRINT OR TYPE NAMEATTORNEY REGISTRATION NUMBER

GGGGGGGGGGGG

ZipState

ZipState

ZipState

ZipState

Name change

Petitioner

Print Form

SAMPLEDoe

John

John Doe

SAMPLEAlbany

John Doe

His

Tim Doe

John Doe

600 East Broadway

city Syracuse Albany

21

John Doe Glendale, California

01/14/1969 45

----- Tim Doe

4. The petitioner is / is not a natural born citizen of United States.

5. The petitioner is / is not married and has / has not been married previously.

6. The petitioner: (Check One):

______ has never been convicted of a crime.

______ has been convicted of a crime, the details of which are attached in a separate statement, annexed hereto and made a part hereof.

7. The petitioner: (Check One):

______ has never been adjudicated a bankrupt.

______ has been adjudicated a bankrupt, the details of which are attached in a separate statement, annexed hereto and made a part hereof.

8. The petitioner: (Check One):

______ There are no judgments or liens of record against the petitioner or actions or proceedings to which the petitioner is a party.

______ There are judgments, liens of records pending against the petitioner or actions or proceedings to which the petitioner is a party, the details of which are attached in a separate statement, annexed hereto and made a part hereof.

9. There are no claims, demands, liabilities, or obligations of any kind whatsoever on a written instrument or otherwise against your infants under the only names by which they have been known, which are the names sought herein to be abandoned, and your infants have no creditors who may be adversely affected or prejudiced in any way by the proposed change of name.

10. The petitioner is / is not responsible for child support obligations. (If there are child support obligations, details are attached in a separate statement)

11. The petitioner is / is not responsible for spousal support obligations. (If there are spousal support obligations, details are attached in a separate statement)

12. The grounds of this application to change the petitioner’s name are as follows:

SAMPLE-------

------- ----

X

X

X

---

---

I am already known by the proposed name in my profession, and I would like to use this name in all my personal and business dealings.

13. The petitioner: (Check One):

______ has made no previous application to change his or her name in this or any other Court.

______ has made a previous application to change his or her name, the details of which are attached in a separate statement, annexed hereto and made a part hereof.

WHEREFORE, petitioner respectfully prays for an order permitting the petitioner _____________________________ to assume the name ______________________________________ in place of that of ______________________________________.

(Current Name)

DATED: ________________, 20___.

_________________________________(Signature of petitioner)

SAMPLEX

John DoeTim DoeJohn Doe

Attachment to Petition for a Name Change:

In the Matter of the Application of _______________________________

For Leave to Change Name to ___________________________________

6. The petitioner has been convicted of the following crime(s):

_____________________________________________________________________________________________________________________________________________________________________________________________

7. The petitioner has been adjudicated a bankrupt, the details of which are as follows:

_____________________________________________________________________________________________________________________________________________________________________________________________

8. There are the following judgments or liens of record against the petitioner:

_____________________________________________________________________________________________________________________________________________________________________________________________

9. There are the following actions or proceedings pending to which the petitioner is a party:

_____________________________________________________________________________________________________________________________________________________________________________________________

10. The petitioner has the following child support obligations:

_____________________________________________________________________________________________________________________________________________________________________________________________

11. The petitioner has the following spousal support obligations:

_____________________________________________________________________________________________________________________________________________________________________________________________

SAMPLETim Doe

John Doe

12. The petitioner has made a previous application to change his or her name in this or any other Court, the details of which are as follows:

_____________________________________________________________________________________________________________________________________________________________________________________________

SAMPLEFrom Ken Doe to John Doe, 04/12/1990, Albany, New York, adoption

SAMPLEJohn Doe

Tim Doe

John Doe

Tim Doe

John Doe

John Doe

Syracuse Albany New York

BC #123456

Tim Doe

SAMPLEAlbany

Albany

Tim Doe

John Doe

600 E. Broadway Syracuse, New York 11788

01/14/1969

Tim Doe

Albany

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SAMPLE