Appendix XXIII - Pretrial Information Exchange (R. 4:25-7(b)

APPENDIX XXIII

Pretrial Information Exchange (R. 4:25-7(b))


In cases that have not been pretried, attorneys shall confer and exchange the
following information seven days prior to the initial trial date, unless such exchange has
been waived by written consent of the parties pursuant to R. 4:25-7(d):

1. A list of all witnesses (including addresses) to be called in the party=s case in
chief.

2. A list of all exhibits to be offered in the party=s case in chief, including all
demonstrative exhibits prepared, prior to trial, by any witness, including an expert
witness. All such exhibits shall be premarked for identification and shall be
described briefly. Each party shall confer in advance of trial to determine if any
such exhibits can be admitted into evidence by agreement or without objection.

3. A list of any proposed deposition or interrogatory reading(s) by page and line
number or by question number.

4. Any in limine or trial motions intended to be made at the commencement of trial,
with supporting memoranda. Such motions shall not go on the regular motion
calendar.

Any objections to the proposed admission into evidence of any exhibit or to any
reading by any other party, and any response to an in limine or trial motion shall
be served on all parties not later than 2 days prior to trial.

5. A listing of all anticipated problems with regard to the introduction of evidence in
each party=s case in chief, especially, but without limitation, as to any hearsay
problems, and legal argument as to all such anticipated evidence problems.

At trial and prior to opening statements, each party shall submit the following to
the trial judge:

(a) copies of any Pretrial Information Exchange materials that have been
exchanged pursuant to this rule, and any objections made thereto; and

(b) stipulations reached on contested procedural, evidentiary and substantive
issues.

In addition, in jury trials each party shall submit the following materials to the
trial judge and, unless exchange of trial information has been waived in writing
pursuant to R. 4:25-7(d), also to all other parties:

(a) any special voir dire questions,

(b) a list of proposed jury instructions with specific reference to the Model
Civil Jury Charges, if applicable,

(c) any special jury instructions with applicable legal authority, and

(d) a proposed jury verdict form that includes all possible verdicts the jury
may return.



Note: Appendix XXIII adopted July 5, 2000 to be effective September 5, 2000;
introduction and paragraph 5 amended July 12, 2002 to be effective September 3, 2002;
paragraph 2 amended July 28, 2004 to be effective September 1, 2004.

Appendix XXII-B - Uniform Commercial Arbitration Memorandum (R. 4:21A-4)

UNIFORM COMMERCIAL ARBITRATION MEMORANDUM
(All Information Must Be Legibly Printed Or Typed)


PLEASE RETURN TO:





Number of Witnesses you are Anticipated length of time
offering at Arbitration: for your presentation:


1. Brief factual outline as to your position:





2. Set forth disputed facts and issues by any party in outline form:





3. Provide facts that you anticipate will be undisputed:





4. Set forth legal issues to be addressed by arbitrator:





5. Please quantify elements of your alleged damages:





6. Set forth issues addressed in expert reports (attach copies):








Revised 7/13/2000, CN 10506-English page 1 of 2

7. Discuss mitigation of damages (if applicable):





8. Describe the basis for the defenses you assert to the complaint and/or counterclaim:






9. Have all parties been served: Yes No
10. Are any parties in default? Yes No
11. ist any unserved and/or defaulted parties: L







12. Should any special expertise be required by the arbitrator, e.g., should the arbitrator be familiar with a
particular discipline and/or industry? If yes, please specify:







I certify this information to be complete and accurate and that copies of this statement have been
timely served on all adversaries pursuant to R. 4:21A-4.



Signature of Attorney or Pro Se Litigant Date




(Please print or type name)




Attorney For





NOTE: Information provided on this form can not be used for
evidentiary purposes in any trial of this matter.


Revised 7/13/2000, CN 10506-English page 2 of 2

Appendix XXII-A - Uniform Arbitration Statement of Facts (R. 4:21A-4)

UNIFORM ARBITRATION STATEMENT OF FACTS
(Use for all but Commercial Cases)


Caption:
(Please include Consolidated Case Docket No. If applicable) (Verbal Threshold)
Yes

No

Docket No: Arbitration Date/Time:

Auto:

P.I.


Party Represented:

I. Briefly describe the accident/incident occurred. (Please attach police report or expert liability reports):






II. Liability (Please attach expert reports)





III. Damages
A. Non-Economic Losses
l. List injuries (Please attach only hospital discharge summary and/or narrative reports/IME)




2. List objective testing and dates.




3. List current treatments and complaints.





Revised 7/13/2000, CN 10505-English page 1 of 2
B. Economic Losses (List all out of pocket expenses)
1. Itemized list of all medical bills

Treating Doctor/Hospital/Other Total Amount Unpaid Bills








2. Net Wage Loss (List all out of pocket expenses)
3. Miscellaneous expense (Please itemize)






C. Workers’ Compensation and Other Liens (please list)





IV. Other issues you contend that the arbitrator should consider:






I certify this information to be complete and accurate and that copies of this statement have been
timely served on all adversaries pursuant to R. 4:21A-4.



Signature of Attorney or Pro Se Litigant Date




(Please print or type name)


Attorney for:


PLEASE DO NOT SEND COPIES OF BILLS, DEPOSITION TRANSCRIPTS,
INTERROGATORIES, OR COPIES OF PHOTOGRAPHS. HOWEVER, BE PREPARED
TO BRING COPIES OF RELEVANT EVIDENCE.
NOTE: Information provided on this form can not be used for
evidentiary purposes in any trial of this matter

Amount
Amount
Revised 7/13/2000, CN 10505-English page 2 of 2

APPENDIX XX CIVIL CASE MANAGEMENT/TRIAL MANAGEMENT GUIDELINES

APPENDIX XX

CIVIL CASE MANAGEMENT/TRIAL MANAGEMENT GUIDELINES

Track Assignment

• Track assignment should not change to accommodate a party’s (or the parties’) need
for a longer discovery period; rather the party(ies) may apply to the court for an
extension of the discovery end date.
• Individual judge management may be available to cases on Tracks I, II and III, if the
court determines it to be necessary, either on the request of a party or sua sponte; this
degree of management, however, should not result in reassignment of the case to Track
IV.
• The assignment of a case to a designated judge, who shall handle all motions and
management conferences in the case through the discovery end date, is not intended to
preclude a judge other than the designated judge from handling a settlement conference
in any case; nor is it intended to preclude block scheduling of settlement conferences
(e.g., “settlement days” involving many cases from a designated carrier).

Motions

• Civil Presiding Judges should be knowledgeable as to which motion decisions are
reserved, and address delays on a judge-to-judge basis, as needed. The Civil Practice
Committees of the county bar associations should be encouraged to discuss with their
Civil Presiding Judges problems with long-reserved decisions. In addition, any attorney
involved in a case in which a decision on a motion has been reserved may make
application to the Civil Presiding Judge to have that motion decided on a timely basis.
• Motions must always be assigned a return date; if no return date is indicated in the
notice of motion, then the motion should be assigned to be heard on the next available
motion date.
• Motions should not be adjourned without being assigned another hearing date.
• The court should make every effort to accommodate attorneys’ requests to schedule oral
argument on motions at a particular time.
• The use of the telephone to hear oral argument should be encouraged, and attorneys’
requests for telephone argument should be accommodated where possible.

Complementary Dispute Resolution (CDR)

• The mandatory scheduling of arbitration in most civil cases should not preclude the use
of other CDR procedures at any time.
• Increased use of mediation at the earliest possible time in the progress of a case should
be encouraged. Mediation should be available at any stage of the proceedings, either at
the parties’ request or on the court’s order, pursuant to R. 1:40-4.
• Early mediation should be considered for all fee-shifting cases (e.g., cases brought
under the Law Against Discrimination) as well as for all fund-in court cases.

Calendar Practices/Trials

• Trial date (or at least trial week) certainty is the goal.
• As a matter of policy, no county shall hold an advance calendar call.
• On the day of the call, attorneys should be released by early afternoon unless their
cases are sent out for settlement discussion or trial, or can reasonably be expected to be
sent out for settlement discussion or trial that day. Attorneys need not appear at trial
calls subsequent to the initial call for their case in the trial week unless the case can
reasonably be expected to be sent out for settlement discussions or trial on that
subsequent date.
• Cases may be listed for trial call on the first three days of a trial week. This guideline is
not intended to preclude other non-trial proceedings, such as proofs and friendlies, from
being listed for the remaining days.
• In no event shall the number of cases listed during a trial week exceed the number that
a county can reasonably expect to reach in that week.
• The court shall not routinely require personal appearance to request adjournment of a
scheduled trial date.
• No county shall implement or maintain a policy that calls for routine bifurcation of a
particular type of case.


[Appendix XX adopted July 5, 2000 to be effective September 5, 2000.]

Appendix XII-E - Writ of Wage Execution

Appendix XII-E
WRIT OF WAGE EXECUTION

Attorneys for Plaintiff


SUPERIOR COURT OF NEW JERSEY
DIVISION, COUNTY
Plaintiff,
DOCKET NO:
vs.


WRIT OF WAGE EXECUTION
Defendant.


THE STATE OF NEW JERSEY

TO THE SHERIFF OF COUNTY

YOU ARE HEREBY COMMANDED that of the weekly earnings which the Defendant
_________________________receives from employer __________________________ whose
address is _______________________________________________, you take the sum of 10%
of the gross weekly pay or 25% of disposable earnings for that week or the amount by which the
designated Defendant’s disposable weekly earnings exceed $217.50 [$196.50] per week,
pursuant to the Order for Wage Execution entered with this Court on ________________, a
copy of which is attached hereto and Certification of the Court entered in the sum of
$ ___________ plus interest and fees until $ plus interest and fees is paid and
satisfied, and that you pay weekly to the Plaintiff’s duly authorized attorney said amount of
reservation of salary.
YOU ARE FURTHER COMMANDED that the employer shall immediately give the
designated defendant a copy of this order. The designated defendant may object to the wage
execution or apply for a reduction in the amount withheld at any time. To object or apply for a
reduction, a written statement of the objection or reasons for a reduction must be filed with the
Clerk of the Court and a copy must be sent to the creditor’s attorney or directly to the creditor if

there is no attorney. A hearing will be held within seven days after filing the objection or
application for a reduction. According to law, no employer may terminate an employee because
of a garnishment.
YOU ARE HEREBY FURTHER COMMANDED that upon satisfaction of Plaintiff’s
damages, costs and interests, plus subsequent costs, or upon termination of the Defendant’s
salary, you will immediately thereafter return this Writ to the Court with a statement as to the
execution annexed.
WITNESS, the Honorable _____________________________, Judge of the Superior
Court, this ______day of , 20 .

_____________________________, CLERK
ENDORSEMENT
Judgment Amount*......................................... $
Additional Costs.............................................. $
Interest thereon.................................................. $
Credits......................................................... $
Sheriff’s Fees................................................. $
Sheriff’s Commissions...................................... $
TOTAL: $
* “Judgment Amount” includes amount of verdict or settlement, plus pre-judgment court costs,
plus any applicable statutory attorney’s fee.

Post-judgment interest applied pursuant to Rule 4:42-11 must be calculated as simple
interest. As required by Rule 4:59-1, explain in detail the method by which interest has been
calculated, taking into account all partial payments made by the defendant.

___________________________
Attorney for Plaintiff

Dated: , 20 __



[Note: Form adopted as Appendix XII-E July 27, 2006 to be effective September 1, 2006; amended September 11, 2006 to be
effective immediately; amended July 3, 2007, to be effective July 24, 2007; amended July 2 , 2008, to be effective July 24, 2008;
amended July 9, 2009 to be effective July 24, 2009.]

Appendix XII-D - Writ of Execution

Appendix XII-D
WRIT OF EXECUTION


Attorney for Plaintiff SUPERIOR COURT OF NEW JERSEY
LAW DIVISION

COUNTY

Plaintiff DOCKET NO:

Vs


Defendant
WRIT OF EXECUTION



THE STATE OF NEW JERSEY

TO THE SHERIFF OF _______________________________

WHEREAS, on the day of judgment was recovered by
Plaintiff, in an action in the Superior Court of New Jersey, Law
Division, County, against Defendant, for damages of
$ and costs of $ ; and

WHEREAS, on , the judgment was entered in the civil docket of
the Clerk of the Superior Court, and there remains due thereon $________________________.

THEREFORE, WE COMMAND YOU that you satisfy the said Judgment out of the
personal property of the said Judgment debtor within your County; and if sufficient personal
property cannot be found then out of the real property in your County belonging to the judgment
debtor(s) at the time when the judgment was entered or docketed in the office of the Clerk of this
Court or at any time thereafter, in whosesoever hands the same may be, and you pay the said
monies realized by you from such property to , Esq., attorney in this
action; and that within twenty-four months after the date of its issuance you return this execution
and your proceedings thereon to the Clerk of the Superior Court of New Jersey at Trenton.

WE FURTHER COMMAND YOU, that in case of a sale, you make your return of this
Writ with your proceedings thereon before this Court and you pay to the Clerk thereof any
surplus in your hands within thirty days after the sale.

WITNESS, HONORABLE a Judge of the Superior
Court, at this day of , 20 .

__________________________,CLERK


ENDORSEMENT

Judgment Amount*: $___________
Additional Costs: $___________
Interest thereon: $___________
Credits: $___________
Sheriff’s Fees: $___________
Sheriff’s Commissions: $___________

TOTAL $___________

*“Judgment Amount” includes amount of verdict or settlement, plus pre-judgment court
costs, plus any applicable statutory attorney’s fee.
Post Judgment Interest applied pursuant to CR 4:42-11 has been calculated as simple
interest. As required by CR 4:59-1, attached is the method by which interest has been calculated,
taking into account all partial payments made by the defendant.


_______________________________
Attorney for Plaintiff

Dated: , 200


Note: Form adopted as Appendix XII-D July 27, 2006 to be effective September 1, 2006;
amended September 11, 2006 to be effective immediately; amended July 9, 2008 to be effective
September 1, 2008.

Appendix XII-C - Authorization to Release Private Health Care Information

[Note: Form adopted as Appendix XII-C July 27, 2006 to be effective September 1, 2006.]

Appendix XII-C (new)

AUTHORIZATION TO RELEASE PRIVATE HEALTH CARE INFORMATION
AND FOR VOLUNTARY INTERVIEW


TO: __________________________ RE: _______________________
__________________________ DOB: _______________________
__________________________ SS#: _______________________

I hereby authorize you to disclose my protected health information to and to
participate in a voluntary interview with:
_________________________________________
_________________________________________
_________________________________________

In defending against the lawsuit I have filed against ___________________, the
defendant is entitled to seek to interview witnesses with relevant information. Your
participation in any such interview is entirely voluntary. You have the right to have my
attorney present at the interview.


You may disclose protected information reasonably related to the medical
condition I have place in issue by my lawsuit. That condition relates to:

_________________________________________
_________________________________________
This authorization may be revoked by me at any time, and expires 120 days from
the date I execute the authorization as indicated below. If you have questions relating to
the scope of this authorization, you may contact your own attorney or my attorney:

__________________________________________
__________________________________________
__________________________________________
Patient signature: ___________________________________ Date: _____________

Appendix XII-B1 - (Civil Case Information Statement (Civil CIS)

Appendix XII-B1

CIVIL CASE INFORMATION STATEMENT FOR USE BY CLERK’S OFFICE ONLY
(CIS) PAYMENT TYPE: CK CG CA
CHG/CK NO.
AMOUNT:

OVERPAYMENT:




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.
BATCH NUMBER:

ATTORNEY/PRO SE NAME


TELEPHONE NUMBER
COUNTY OF VENUE
FIRM NAME (If applicable)


DOCKET NUMBER (When available)

DOCUMENT TYPE OFFICE ADDRESS





JURY DEMAND
YES NO
NAME OF PARTY (e.g., John Doe, Plaintiff)


CAPTION

CASE TYPE NUMBER
(See reverse side for listing) 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.
RELATED CASES PENDING?

YES NO
IF YES, LIST DOCKET NUMBERS
DO YOU ANTICIPATE ADDING
ANY PARTIES (arising out of same
transaction or occurrence)?


YES NO
NAME OF DEFENDANT’S PRIMARY INSURANCE COMPANY, IF KNOWN

ONE N
UNKNOWN
THE INFORMATION PROVIDED ON THIS FORM CANNOT BE INTRODUCED INTO EVIDENCE.
CASE CHARACTERISTICS FOR PURPOSES OF DETERMINING IF CASE IS APPROPRIATE FOR MEDIATION
DO PARTIES HAVE A CURRENT,
PAST OR RECURRENT
RELATIONSHIP? YES NO
IF YES, IS THAT
RELATIONSHIP EMPLOYER-EMPLOYEE FRIEND/NEIGHBOR THER (explain) O
FAMILIAL BUSINESS
DOES THE STATUTE GOVERNING THIS
CASE PROVIDE FOR PAYMENT OF FEES
BY THE LOSING PARTY?

YES NO
USE THIS SPACE TO ALERT THE COURT TO ANY SPECIAL CASE CHARACTERISTICS THAT MAY WARRANT INDIVIDUAL MANAGEMENT OR ACCELERATED
DISPOSITION:





DO YOU OR YOUR CLIENT NEED ANY
DISABILITY ACCOMMODATIONS? YES NO IF YES, PLEASE IDENTIFY THE REQUESTED ACCOMMODATION:

WILL AN INTERPRETER BE NEEDED?



YES NO IF YES, FOR WHAT LANGUAGE:

I certify that confidential personal identifiers have been redacted from documents now submitted to the court, and will be
redacted from all documents submitted in the future in accordance with Rule 1:38-7(b).
ATTORNEY SIGNATURE:
Revised Effective 9/2009, CN 10517



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




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

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

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

Centrally Managed Litigation (Track IV)
280 Zelnorm
285 Stryker Trident Hip Implants

Mass Tort (Track IV)
248 CIBA GEIGY 279 GADOLINIUM
266 HORMONE REPLACEMENT THERAPY (HRT) 281 BRISTOL-MYERS SQUIBB ENVIRONMENTAL
271 ACCUTANE 282 FOSAMAX
272 BEXTRA/CELEBREX 283 DIGITEK
274 RISPERDAL/SEROQUEL/ZYPREXA 284 NUVARING
275 ORTHO EVRA 286 LEVAQUIN
277 MAHWAH TOXIC DUMP SITE 601 ASBESTOS
278 ZOMETA/AREDIA 619 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
Revised Effective 9/2009, CN 10517
SIDE 2

Appendix XII-A - Summons

APPENDIX XII-A. SUMMONS
Attorney(s):
Office Address & Tel. No.:
Attorney(s) for Plaintiff(s)
________________________________________
SUPERIOR COURT OF NEW JERSEY
_________________COUNTY
________________DIVISION

Plaintiff(s) Docket No._____________

vs. CIVIL ACTION


Defendant(s) SUMMONS
________________________________________

From The State of New Jersey To The Defendant(s) Named Above:

The plaintiff, named above, has filed a lawsuit against you in the Superior Court of New
Jersey. The complaint attached to this summons states the basis for this lawsuit. If you dispute
this complaint, you or your attorney must file a written answer or motion and proof of service
with the deputy clerk of the Superior Court in the county listed above within 35 days from the
date you received this summons, not counting the date you received it. (The address of each
deputy clerk of the Superior Court is provided.) If the complaint is one in foreclosure, then you
must file your written answer or motion and proof of service with the Clerk of the Superior Court,
Hughes Justice Complex, P.O. Box 971, Trenton, NJ 08625-0971. A filing fee payable to the
Treasurer, State of New Jersey and a completed Case Information Statement (available from the
deputy clerk of the Superior Court) must accompany your answer or motion when it is filed. You
must also send a copy of your answer or motion to plaintiff's attorney whose name and address
appear above, or to plaintiff, if no attorney is named above. A telephone call will not protect your
rights; you must file and serve a written answer or motion (with fee of $135.00 and completed
Case Information Statement) if you want the court to hear your defense.

If you do not file and serve a written answer or motion within 35 days, the court may enter a
judgment against you for the relief plaintiff demands, plus interest and costs of suit. If judgment
is entered against you, the Sheriff may seize your money, wages or property to pay all or part of
the judgment.

If you cannot afford an attorney, you may call the Legal Services office in the county where
you live. A list of these offices is provided. If you do not have an attorney and are not eligible
for free legal assistance, you may obtain a referral to an attorney by calling one of the Lawyer
Referral Services. A list of these numbers is also provided.

________________________________

Clerk of the Superior Court
DATED:

Name of Defendant to Be Served:

Address of Defendant to Be Served:

-------------------------------------------------------

ATLANTIC COUNTY:
Deputy Clerk of the Superior Court
Civil Division, Direct Filing
1201 Bacharach Blvd., First Fl.
Atlantic City, NJ 08401
LAWYER REFERRAL
(609) 345-3444
LEGAL SERVICES
(609) 348-4200

BERGEN COUNTY:
Deputy Clerk of the Superior Court
Case Processing Section, Room 119
Justice Center, 10 Main St.
Hackensack, NJ 07601-0769
LAWYER REFERRAL
(201) 488-0044
LEGAL SERVICES
(201) 487-2166

BURLINGTON COUNTY:
Deputy Clerk of the Superior Court
Central Processing Office
Attn: Judicial Intake
First Fl., Courts Facility
49 Rancocas Rd.
Mt. Holly, NJ 08060
LAWYER REFERRAL
(609) 261-4862
LEGAL SERVICES
(800) 496-4570

CAMDEN COUNTY:
Deputy Clerk of the Superior Court
Civil Processing Office
1st Fl., Hall of Records
101 S. Fifth St.
Camden, NJ 08103
LAWYER REFERRAL
(856) 964-4520
LEGAL SERVICES
(856) 964-2010

CAPE MAY COUNTY:
Deputy Clerk of the Superior Court
9 N. Main Street
Box DN-209
Cape May Court House, NJ 08210
LAWYER REFERRAL
(609) 463-0313
LEGAL SERVICES
(609) 465-3001

CUMBERLAND COUNTY:
Deputy Clerk of the Superior Court
Civil Case Management Office
Broad & Fayette Sts., P.O. Box 615
Bridgeton, NJ 08302
LAWYER REFERRAL
(856) 692-6207
LEGAL SERVICES
(856) 451-0003

ESSEX COUNTY:
Deputy Clerk of the Superior Court
50 West Market Street
Room 131
Newark, NJ 07102
LAWYER REFERRAL
(973) 622-6207
LEGAL SERVICES
(973) 624-4500

GLOUCESTER COUNTY:
Deputy Clerk of the Superior Court
Civil Case Management Office
Attn: Intake
First Fl., Court House
1 North Broad Street, P.O. Box 750
Woodbury, NJ 08096
LAWYER REFERRAL
(856) 848-4589
LEGAL SERVICES
(856) 848-5360

HUDSON COUNTY:
Deputy Clerk of the Superior Court
Superior Court, Civil Records Dept.
Brennan Court House--1st Floor
583 Newark Ave.
Jersey City, NJ 07306
LAWYER REFERRAL
(201) 798-2727
LEGAL SERVICES
(201) 792-6363

HUNTERDON COUNTY:
Deputy Clerk of the Superior Court
Civil Division
65 Park Avenue
Flemington, NJ 08822
LAWYER REFERRAL
(908) 263-6109
LEGAL SERVICES
(908) 782-7979

MERCER COUNTY:
Deputy Clerk of the Superior Court
Local Filing Office, Courthouse
175 S. Broad Street, P.O. Box 8068
Trenton, NJ 08650
LAWYER REFERRAL
(609) 585-6200
LEGAL SERVICES
(609) 695-6249

MIDDLESEX COUNTY:
Deputy Clerk of the Superior Court
Administration Building
Third Floor
1 Kennedy Sq., P.O. Box 2633
New Brunswick, NJ 08903-2633
LAWYER REFERRAL
(732) 828-0053
LEGAL SERVICES
(732) 249-7600

MONMOUTH COUNTY:
Deputy Clerk of the Superior Court
Court House
71 Monument Park
P.O. Box 1269
Freehold, NJ 07728-1269
LAWYER REFERRAL
(732) 431-5544
LEGAL SERVICES
(732) 866-0020

MORRIS COUNTY:
Deputy Clerk of the Superior Court
Civil Division
30 Schuyler Pl., P.O. Box 910
Morristown, NJ 07960-0910
LAWYER REFERRAL
(973) 267-5882
LEGAL SERVICES
(973) 285-6911

OCEAN COUNTY:
Deputy Clerk of the Superior Court
Court House, Room 119
118 Washington Street
Toms River, NJ 08754
LAWYER REFERRAL
(732) 240-3666
LEGAL SERVICES
(732) 341-2727

PASSAIC COUNTY:
Deputy Clerk of the Superior Court
Civil Division
Court House
77 Hamilton St.
Paterson, NJ 07505
LAWYER REFERRAL
(973) 278-9223
LEGAL SERVICES
(973) 523-2900

SALEM COUNTY:
Deputy Clerk of the Superior Court
92 Market St., P.O. Box 18
Salem, NJ 08079
LAWYER REFERRAL
(856) 678-8363
LEGAL SERVICES
(856) 451-0003

SOMERSET COUNTY:
Deputy Clerk of the Superior Court
Civil Division Office
New Court House, 3rd Fl.
P.O. Box 3000
Somerville, NJ 08876
LAWYER REFERRAL
(908) 685-2323
LEGAL SERVICES
(908) 231-0840

SUSSEX COUNTY:
Deputy Clerk of the Superior Court
Sussex County Judicial Center
43-47 High Street
Newton, NJ 07860
LAWYER REFERRAL
(973) 267-5882
LEGAL SERVICES
(973) 383-7400

UNION COUNTY:
Deputy Clerk of the Superior Court
1st Fl., Court House
2 Broad Street
Elizabeth, NJ 07207-6073
LAWYER REFERRAL
(908) 353-4715
LEGAL SERVICES
(908) 354-4340

WARREN COUNTY:
Deputy Clerk of the Superior Court
Civil Division Office
Court House
413 Second Street
Belvidere, NJ 07823-1500
LAWYER REFERRAL
(908) 387-1835
LEGAL SERVICES
(908) 475-2010

______________

[Note: Adopted July 13, 1994, effective September 1, 1994; amended June 28, 1996,
effective September 1, 1996; address/phone information updated July 1, 1999, effective
September 1, 1999; amended July 12, 2002 to be effective September 3, 2002; amended
July 27, 2006 to be effective September 1, 2006; address/phone information updated
October 10, 2006 to be effective immediately; address/phone information updated
November 1, 2006 to be effective immediately; address/phone information updated
November 17, 2006 to be effective immediately.]

Appendix XI-X - Verified Complaint – Nonpayment of Rent

APPENDIX XI-X. VERIFIED COMPLAINT – NONPAYMENT OF RENT

[Rule 6:3-4(c)]

Attorney(s)/Pro Se: _________________ SUPERIOR COURT OF NEW JERSEY
Office Address: ____________________ Law Division, Special Civil Part
Phone No.: ________________________ ______________ County
Docket No.: LT - ________________
Name of Plaintiff(s)/Landlord(s):
Civil Action

vs VERIFIED COMPLAINT
LANDLORD/TENANT
Name of Defendant(s)/Tenant(s):
___ Non-payment of Rent
___ Other (Required Notices Attached)


Address of Rental Premises: ______________________________________________________
Tenant’s Phone No.: ___________________

1. The owner of record is _______________________________________________.
(name of owner)

2. Plaintiff is the owner or (check one) ___agent, ___assignee, ___grantee or ___ prime tenant
of the owner.

3. The landlord __ did __ did not acquire ownership of the property from the tenant(s).

4. The landlord __ has __ has not given the tenant(s) an option to purchase the property.

5. The tenant(s) now reside(s) in and has (have) been in possession of these premises since ,
under (check one) __written or __oral agreement. (mm/dd/yyyy)

6. ___ Check here if the tenancy is subsidized pursuant to either a federal or state program or the rental unit is
public housing.

7. The landlord has registered the leasehold and notified tenant as required by N.J.S.A. 46:8-27.

8. The amount that must be paid by the tenant(s) for these premises is $_________, payable on the ___ day of
each __month or __week in advance.

COMPLETE PARAGRAPHS 9A AND 9B IF COMPLAINT IS FOR NON-PAYMENT OF RENT

9A. There is due, unpaid and owing from tenant(s) to plaintiff/landlord rent as follows:
$________ base rent for __________________________ (specify the week or month)
$________ base rent for __________________________ (specify the week or month)
$________ base rent for __________________________ (specify the week or month)
$________ late charge* for ________________________ (specify the week or month)
$________ late charge* for ________________________ (specify the week or month)
$________ late charge* for ________________________ (specify the week or month)
$________ attorney fees*
$________ other* (specify ___________)
$________ court costs (fees for filing and serving the complaint)
$________ TOTAL

*The late charges, attorney fees and other charges are permitted to be charged as rent for
purposes of this action by federal, state and local law (including rent control and rent
leveling) and by the lease.

9B. The date that the next rent is due is _________________.
(mm/dd/yyyy)
If this case is scheduled for trial before that date, the total amount you must pay to have this
complaint dismissed is $___________________.
(Total from line 9A)

If this case is scheduled for trial on or after that date, the total amount you must pay to have
this complaint dismissed is $_________________________________________________.
(Total from line 9A plus the amount of the next rent due)

These amounts do not include late fees or attorney fees for Section 8 and public housing
tenants. Payment may be made to the landlord or the clerk of the court at any time before the
trial date, but on the trial date payment must be made by 4:30 p.m. to get the case dismissed.

CHECK PARAGRAPHS 10 AND 11 IF THE COMPLAINT IS FOR OTHER THAN OR IN
ADDITION TO NON-PAYMENT OF RENT. ATTACH ALL NOTICES TO CEASE AND
NOTICES TO QUIT/DEMANDS FOR POSSESSION.

10. ___ Landlord seeks a judgment for possession for the additional or alternative reason(s)
stated in the notices attached to this complaint. STATE REASONS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Attach additional sheets if necessary.)




11. ___ The tenant(s) has (have) not surrendered possession of the premises and tenant(s) hold(s)
over and continue(s) in possession without the consent of landlord.

WHEREFORE, plaintiff/landlord demands judgment for possession against the tenant(s) listed
above, together with costs.


DATED: _________________
_____________________________________________
(Signature of Filing Attorney or Landlord Pro Se)

_____________________________________________
(Printed or Typed Name of Attorney or Landlord Pro Se)


LANDLORD VERIFICATION


1. I certify that I am the ___ landlord, ___general partner of the partnership, or ___ authorized
officer of a corporation or limited liability company that owns the premises in which tenant(s)
reside(s).

2. I have read the verified complaint and the information contained in it is true and based on my
personal knowledge.

3. The matter in controversy is not the subject of any other court action or arbitration proceeding
now pending or contemplated and no other parties should be joined in this action except (list
exceptions or indicate none): ______________________________.

4. The foregoing statements made by me are true and I am aware that if any of the foregoing
statements made by me are willfully false, I am subject to punishment.


DATED: _________________
_____________________________________________
(Signature of Landlord, Partner or Officer)

_____________________________________________
(Printed Name of Landlord, Partner or Officer


[Note: Adopted as Appendix XI-X July 9, 2008 to be effective September 1, 2008.]

Appendix XI-W - Consent to Enter Judgment for Possession (Tenant Vacates)

APPENDIX XI-W
CONSENT TO ENTER JUDGMENT FOR POSSESSION (TENANT VACATES)
Plaintiff :
:
:
v. :
:
:
Defendant :
:
SUPERIOR COURT OF NEW JERSEY
LAW DIVISION, SPECIAL CIVIL PART
COUNTY
LANDLORD-TENANT DIVISION
DOCKET # LT
CONSENT TO ENTER JUDGMENT
(TENANT REQUIRED TO VACATE)
THE TENANT AND LANDLORD HEREBY AGREE THAT:
1. The Tenant AGREES TO THE IMMEDIATE ENTRY OF A JUDGMENT FOR POSSES-
SION.
2. Check one of the following:
A. The Tenant shall pay no money, or
B. The Tenant shall pay $ , as follows:
3. A. If the Tenant does not make all payments required in paragraph 2 of this Agreement, the Tenant
agrees that the Landlord, with notice to the tenant, can file a certification stating when and what the
breach was and that a warrant of removal will then be issued by the clerk.
B. EVEN IF THE TENANT DOES MAKE ALL PAYMENTS REQUIRED IN PARA-
GRAPH 2, THE TENANT STILL AGREES TO MOVE NO LATER THAN
. IF THE TENANT DOES NOT MOVE BY THAT DATE, LAND-
LORD CAN HAVE THE TENANT EVICTED AS PERMITTED BY LAW.
DATE: ____________________
___________________________________ ______________________________
Landlord’s Attorney Tenant’s Attorney
___________________________________ _______________________________
Landlord Tenant
NOTE: THE CERTIFICATION BY LANDLORD AND THE CERTIFICATION OF
LANDLORD’S ATTORNEY (IF THE LANDLORD HAS AN ATTORNEY) ARE ATTACHED
HERETO.
[Note: Appendix XI-W adopted July 18, 2001 to be effective November 1, 2001.]

Appendix XI-V - Consent to Enter Judgment

APPENDIX XI-V — CONSENT TO ENTER JUDGMENT (TENANT REMAINS)
Plaintiff
v.
Defendant
SUPERIOR COURT OF NEW JERSEY
LAW DIVISION, SPECIAL CIVIL PART
COUNTY
LANDLORD-TENANT DIVISION
DOCKET #LT
CONSENT TO ENTER JUDGMENT
(TENANT TO STAY IN PREMISES)
THE TENANT AND LANDLORD HEREBY AGREE THAT:
1. The Tenant shall pay to the Landlord $ , which the Tenant admits is now due and owing and
AGREES TO THE IMMEDIATE ENTRY OF A JUDGMENT FOR POSSESSION.
2. The Tenant shall pay the amount shown in paragraph 1 as follows:
a. $ immediately, which the Landlord admits receiving.
b. The Tenant shall pay the rest of the amount shown in paragraph 1 as follows:
3. The Tenant also agrees to pay $ each month as required by the rental
agreement, in addition to the payment required in paragraph 1, until this settlement agreement is over.
4. All payments made during the term of this agreement shall be applied first to the rents that become due
after today, and then they shall be applied to pay the balance of the arrears stated in paragraph 1. If the
Tenant makes all payments required in paragraph 2b of this agreement, the Landlord agrees not to
request a warrant of removal. If the Tenant does not make all payments required in paragraph 2b of this
agreement, the Tenant agrees that the Landlord, with notice to the tenant, may file a certification stating
when and what the breach was and that a warrant of removal may then be issued by the clerk.
THIS MEANS THAT IF THE TENANT FAILS TO MAKE ANY PAYMENT THAT IS
REQUIRED IN PARAGRAPH 2b OF THIS AGREEMENT, THE TENANT MAY BE
EVICTED AS PERMITTED BY LAW AFTER THE SERVICE OF THE WARRANT OF
REMOVAL.
5. This agreement shall end when the Tenant has paid the full amount of rent stated in paragraph 1 and then
the judgment shall be vacated and the complaint shall be dismissed.
DATE:
Landlord’s Attorney Tenant’s Attorney
Landlord Tenant
NOTE: THE CERTIFICATION BY LANDLORD AND THE CERTIFICATION OF
LANDLORD’S ATTORNEY (IF THE LANDLORD HAS AN ATTORNEY) ARE ATTACHED
HERETO.
[Note: Appendix XI-V adopted July 18, 2001 to be effective November 1, 2001.]

Appendix XI-U - Certification by Landlord's Attorney

APPENDIX XI-U
CERTIFICATION BY LANDLORD’S ATTORNEY
Attorney’s Name
Address:
Phone:
, Plaintiff
v.
, Defendant
Superior Court of New Jersey
Law Division, Special Civil Part
County
Landlord-Tenant Division
Docket # LT
Certification by Landlord’s Attorney
1. I am the attorney for the landlord in this matter and make this certification pursuant to Rule 6:6-3(b)
or Rule 6:6-4.
2. The landlord has asserted that the tenant has failed to pay rent now due and owing in this matter.
3. I have reviewed the applicable federal, state and local law and the written lease between the
parties, and in my opinion the charges and fees sought, other than the base rent, are permitted to
be included in the rent for purposes of this action.
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 willfully false, I am subject to punishment.
Date:
Printed name:
[Note: Appendix XI-U adopted July 18, 2001 to be effective November 1, 2001.]

Appendix XI-T - Certification by Landlord

APPENDIX XI-T — CERTIFICATION BY LANDLORD

YOU MUST COMPLETE THIS PART:
NAME OF LANDLORD OR ATTORNEY: ________________________________
ADDRESS & PHONE #: ______________________________________________
_______________________________________________________



Plaintiff,

vs.


Defendant.
SUPERIOR COURT OF NEW JERSEY
LAW DIVISION
SPECIAL CIVIL PART
_____________ COUNTY
LANDLORD-TENANT DIVISION

Docket No. LT-__________
Civil Action

CERTIFICATION BY LANDLORD

THE LANDLORD SHOULD COMPLETE PART A OR PART B OR BOTH (IF BOTH APPLY). CROSS OUT ANY
PARAGRAPHS IN THOSE PARTS THAT DO NOT APPLY IN THIS CASE. PART C APPLIES TO ALL CASES AND MUST
BE COMPLETED.

A. WHEN THE EVICTION IS BASED ON UNPAID RENT
1. The tenant has failed to pay rent now due and owing in the amount of $_______________ . That amount consists of
basic rent of $_______________, late charges of $_______________, legal fees relating to this action for eviction
of $_______________, filing fees and costs of $_______________, and other (specify) ______________________.
2. All of the items listed above are included in the lease agreement as rent.
3. All of those items are permitted by applicable federal, state and local laws (including rent control or rent leveling,
if applicable) to be charged as rent for purposes of this action.

B. WHEN THE EVICTION IS BASED ON OTHER GROUNDS
Eviction is sought because



C. IN ALL CASES:
1. I have attached a copy of all notices that have been served on the tenant.
2. These notices were served on the tenant (check one or more) _____ by ordinary mail, _____ by certified mail,
_____ personally, on _____________________________________________________________________.
3. All of the facts stated in the notices are true.
4. If I proceeded without an attorney, I certify that I own the property in my own name or in the name of a general
partnership of which I am a partner.
5. I have complied with the registration requirements of N.J.S.A. 46:8-27 et seq.
6. The tenant did not transfer ownership to me and I have not given the tenant an option to buy the property.
7. The tenant is not in the military service of the United State nor any of its allies, nor is the premises used for
dwelling purposes of the spouse, a child or other dependent of a person in the military service of the United
States.

I, THE LANDLORD, 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.

DATE: _______________ ___________________________________________________________
(PRINT NAME BELOW) LANDLORD

[Note: Appendix XI-T adopted July 18, 2001 to be effective November 1, 2001; amended July 27, 2006 to be
effective September 1, 2006, amended July 9, 2008 to be effective September 1, 2008.]

Appendix XI-S - Landlord/Tenant Pre-calendar Call Instructions

New Jersey Judiciary
Superior Court of New Jersey
Law Division, Special Civil Part
Landlord/Tenant Pre-Calendar Call Instructions

Effective 09/01/2006, CN 10887-English
Preamble
The judge presiding at the call of the landlord/tenant trial list on the day of the trial will provide instructions to the tenants
and landlords who have come to court for a trial. The instructions are set forth below. A written copy of the instructions
provided by the judge will be made available to you at the calendar call. These instructions need not be recited verbatim.
However, what is said must contain and explain in plain language all of the points set forth in these instructions and may
be supplemented by local information. A Spanish version of these instructions will be given via a videotape recording
and in writing in those counties with a significant Spanish speaking population.
Instructions
Si usted necessita un interprete porque usted habla solamente Espanol, por favor, ponga se de pie.
We are about to call a list of cases where the landlord is suing to evict, that is, lock out, a tenant. After the list has been
called, you will have a chance to ask questions. Written copies of the instructions I am about to give are available.
1. The Calendar Call
A. When we call each case, please identify yourself. We will mark a case "READY" when both the landlord and the
tenant are here. We will mark a case "DEFAULT" when the landlord is here but the tenant isn't. If a default is
entered, then the landlord must file an affidavit or certification, which must include the facts necessary to get a
judgment for possession and a statement that all charges and fees are permitted by law and the lease. The
landlord’s attorney, if there is one, must also file a certification that the charges and fees, including attorney fees,
are permitted by law and the lease. The judgment for possession allows a landlord to have a tenant evicted by a
Special Civil Part Officer. We will mark a case "DISMISSED" if the landlord is not here. Tenants should
identify themselves even if the landlord is not here.
B. Everyone must stay here until you get additional instructions and permission to leave.
2. Settlements
Now I want to talk to you about settlements. After we have called the list of cases, we suggest that landlords and tenants
talk to each other to try to settle your cases. Here are some important points. You do not have to settle your case, and you
have the right to a trial. You should settle only if the terms are agreeable to you. A settlement must be voluntary to both
parties. If you are able to agree on a settlement, please let the staff in this courtroom know and you will be given a
settlement agreement form, the landlord’s certification and the certification for the landlord’s attorney. I advise the parties
that they are not limited to the contents of the settlement forms. You may change them as desired. Complete the forms,
date and sign them, and give them back to court staff. You will receive a copy for your own records. Make sure that you
understand the words in the settlement because if you agreed to entry of a judgment for possession and don’t comply with
the terms of the settlement, you will be evicted. Any agreement that says a judgment for possession will or may be
entered must be approved by me or another judge.
3. Waiting for Trial
If you are not able to settle your case, you will have to wait until a judge is available to hear your case. We expect to
reach all cases today. However, if your case cannot be completed today, then the tenant may have to deposit with the
clerk of the court the amount of rent to be determined by the court, no later than 4:30 p.m. today, in cash or money order
or bank cashier's check made payable to the Treasurer, State of New Jersey, rather than to the landlord. If it is deposited,
the Clerk will reschedule the case with a new trial date. If the rent is not deposited today, a Judgment for Possession will
be entered in favor of the landlord. That means that a landlord will be able to have a tenant evicted by a Special Civil Part
Officer. A landlord cannot lock out a tenant by himself or herself; a Special Civil Part Officer must be used to evict a
tenant.
Landlord/Tenant Pre-Calendar Call Instructions
Effective 09/01/2006, CN 10887-English page 2 of 3
4. Non-Payment Cases
Introduction. The following points relate to a landlord's claim that a tenant owes rent:
A. Dismissal Upon Payment or Deposit. First, if the landlord claims that the tenant owes rent, it is still not too late
to pay the rent that is due and have the case dismissed. If the tenant pays the rent that is due plus costs of court by
4:30 p.m. today, the case will be dismissed. The tenant may pay the rent plus costs to the landlord, or to the clerk
of the court by cash, money order, or bank cashier’s check. If a tenant disagrees with the landlord on the amount
of the rent that is owed, a tenant has the right to a trial so that a judge can decide how much rent is owed. After
the judge decides how much rent is owed, the tenant can pay the rent and the case will be dismissed.
B. Items Constituting Rent. A tenant does not have to pay for attorney’s fees, late fees or other charges to avoid
eviction unless there is a written lease that calls these items “additional rent.” Even if the lease does say that, the
amount really due as rent may be limited by rent control, or if there is public assistance, the rent may be limited
by federal law. For example, if the tenant gets Section 8 assistance, the landlord cannot include a late charge to
determine the amount that the tenant owes.
C. Limitation on Court’s Powers. If the only issue is that a tenant who owes rent wants more time to pay it, or to
pay it in installments but the landlord does not agree, then I will have to enter a judgment for possession; I have
no right to make a landlord wait for the rent or to take it in installments. A judgment for possession is the court
order giving the landlord the right to possession of the premises. However, the landlord cannot actually evict the
tenant until the warrant of removal is issued.
5. Eviction Procedures
A. Issuance of Warrant. A judgment for possession gives a landlord the right to request a warrant to have a tenant
evicted by a Special Civil Part Officer. That warrant may be issued no sooner than three business days after entry
of the judgment for possession.
B. Service of the Warrant. The warrant will have to be served by the Officer on the tenant, and a residential tenant
may be evicted no sooner than three business days after it has been served, but not on a weekend or holiday. To
put it very simply, a residential tenant may not be evicted any earlier than 8 days plus holidays, after a judgment
for possession has been entered.
6. Stopping an Eviction After a Judgment for Possession
A. By Agreement. After a judgment for possession has been entered, a tenant may still try to make an agreement
with a landlord to stop an eviction. If the landlord does agree, make sure that the agreement is in writing and that
a copy is filed with the court.
B. By Going to the Court. If the landlord does not agree, then, even after a warrant of removal has been served on a
tenant or after the tenant has been removed, the tenant may apply to the court, as soon as possible, for relief to
stop the eviction or put the tenant back, including:
(1) An Order to Show Cause [based on Court Rule 4:50-1] requesting that the judgment for possession be
reversed and the complaint dismissed, if the tenant can show good reasons.
(2) A delay [stay] of the eviction based on the unavailability of other dwelling accommodations [based on New
Jersey Statute 2A:42-10.1 or 2A:42-10.6]. That delay cannot be for more than 6 months and must be applied
for no later than 10 days after the eviction, but the tenant will have to pay all rent and proper costs.
(3) An application for orderly removal requesting more time to move out if there is a good reason.
A court may grant or deny these applications, and if one of these applications is granted, the court may also establish
certain conditions.
7. Jurisdictional Instruction
Landlords who want to evict a tenant when they either got title from the tenant or gave the tenant an option to purchase,
must stay here to testify in court even if the tenant isn't here. This does not apply to most eviction cases.
Landlord/Tenant Pre-Calendar Call Instructions
Effective 09/01/2006, CN 10887-English page 3 of 3
8. Services/Facilities Available
We have a list of agencies that may assist you with rent, temporary shelter or legal services. A list of these agencies or
legal services programs, and a copy of this announcement, is available, and you should get a copy if you do not have one.
[Identify any welfare representatives who are present in court.]
Please wait until the list of cases has been completed and additional instructions have been
given.

Appendix XI-R - Information Subpoena and Written Questions to Non-Parties

INFORMATION SUBPOENA AND WRITTEN QUESTIONS TO NON-PARTIES
IMPORTANT NOTICE -- PLEASE READ CAREFULLY FAILURE TO COMPLY WITH THIS
INFORMATION SUBPOENA MAY RESULT IN YOU BEING PUNISHED BY THE COURT

Name: SUPERIOR COURT OF NEW JERSEY
Address: LAW DIVISION, SPECIAL CIVIL PART
Telephone No.: ___________ COUNTY
DOCKET NO ________________

Plaintiff, CIVIL ACTION
v.
Defendant. INFORMATION SUBPOENA
Social Security Number (If known) ______________
THE STATE OF NEW JERSEY, TO:
Judgment has been entered against ____________________ (the name of defendant) whose last know address is
in the Superior Court of New Jersey, Law Division, Special Civil Part, ____________County.
Attached to this Information Subpoena is a list of questions that the Court Rules of New Jersey require you to
answer within 14 days from the date you receive this subpoena. You must answer the questions in section ____ A,
B, or _____ C. If you do not answer the attached questions within the time required, the judgment creditor or
judgment creditor's attorney may ask the Court to conduct a hearing in order to determine if you should be held in
contempt. You will be compelled to appear at the hearing and explain your reasons for your failure to answer.
You must answer each question giving complete answers, attaching additional pages if necessary. False or
misleading answers may subject you to punishment by the Court. Be sure to sign and date your answers and return
them to the address in the upper left hand corner within 14 days.

TAKE NOTICE THAT SINCE THIS IS AN OFFICIAL FORM OF THE COURTS OF THE STATE OF
NEW JERSEY, YOU CANNOT REFUSE TO ANSWER ANY OF THE QUESTIONS ON THE GROUNDS
THAT THE INFORMATION IS PRIVILEGED.

DATED:____________________

______________________________ _________________________________________
Attorney For Clerk


SECTION A TO BE ANSWERED BY BANKING INSTITUTIONS
1. Does the named defendant have any checking, savings or other accounts at your bank? Yes ___ No ___
2. If yes, for all such accounts set forth the type of account, the account number and the current balance in the
account.
I 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.
DATED:____________________ ________________
Signature
_______________________________
Print your name and title
SECTION B TO BE ANSWERED BY EMPLOYERS
1. Does the named defendant work for your business at the present time? Yes ___ No ___
2. If yes, set forth the named defendant's gross and net weekly salary, including any overtime if applicable.
3. If the named defendant is no longer employed by your business, and if you know, state the name and address
of the named defendant's current employer.
I 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.
DATED:____________________ ________________________________________________
Signature
_______________________________________________________________
Print your name and title
SECTION C TO BE ANSWERED BY THOSE CONDUCTING BUSINESS WITH THE NAMED
DEFENDANT
1. Has your business ever purchased goods and/or services from the named defendant? Yes ___ No ___
2. Does your business presently purchase goods and/or services from the named defendant? YES ___ NO ___
3. In the future, will your business purchase goods and/or services from the named defendant? YES ___ NO ___
4. Does your business owe any money to the named defendant? YES _____ NO _____ If yes, state the amount
currently owed.
I 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.
DATED:____________________ ________________________________________________
Signature
_______________________________________________________________
Print your name and title

Appendix XI-Q - Warrant for Arrest

APPENDIX XI-Q.

WARRANT FOR ARREST


Name: SUPERIOR COURT OF NEW JERSEY
Address: LAW DIVISION, SPECIAL CIVIL PART
Telephone No. ____________________ County

Docket No. _____________________

____________, Plaintiff CIVIL ACTION
v. WARRANT FOR ARREST
____________, Defendant





TO: A Court Officer of the Special Civil Part or the Sheriff of ____________________ County


You are hereby commanded to arrest ______________, at (check one) [ ] any location, [ ] the
address set forth in the annexed order to enforce litigant’s rights between the hours of 7:30 a.m.
and 3:00 p.m. on a day when the court is in session, and bring him or her forthwith before a
Judge of the Superior Court to await the further order of the Court in this matter.

Local police departments are authorized and directed to provide assistance to the officer
executing this warrant.


Date: ________________ WITNESS: __________________________
Judge of the Superior Court



_________________________
Clerk of the Special Civil Part




[Note: Former Appendix XI-P adopted July 14, 1992, effective September 1, 1992;
redesignated as Appendix XI-Q July 13, 1994, effective September 1, 1994; amended June 28,
1996 to be effective September 1, 1996; amended July 28, 2004 to be effective September 1,
2004.]

Appendix XI-P - Certification in Support of Application for Arrest Warrant

APPENDIX XI-P — CERTIFICATION IN SUPPORT OF
APPLICATION FOR ARREST WARRANT

Name:
Address:
Phone No.:

) SUPERIOR COURT OF NEW JERSEY
) LAW DIVISION, COUNTY
Plaintiff, ) SPECIAL CIVIL PART
)
) DOCKET NO.
vs. )
) CIVIL ACTION
Defendant. )
) CERTIFICATION IN SUPPORT OF
) APPLICATION FOR ARREST WARRANT


The following certification is made in support of plaintiff's application for an arrest
warrant:

1. I am the plaintiff or plaintiff's attorney in this matter.

2. On , 20 , plaintiff obtained a judgment against the defendant, , for $
damages plus costs.

3. (Check all applicable boxes below)

[ ] a. On , 20 , an Order was entered by this Court ordering defendant,
_____________, to appear at on , 20 _ , at .m. and make
discovery on oath as to the defendant's property, and on , 20 _ , a copy of the
Order was served upon (check one) [ ] personally, [ ] by sending it
simultaneously by ordinary and certified mail, return receipt requested to 's
last known address as shown on the discovery Order referenced above.

[ ] b. On , 20 _ , I served an information subpoena and attached
questions as permitted by Court Rules on the defendant, , (check one) [ ]
personally, [ ] by sending it simultaneously by regular and certified mail, return
receipt requested, to defendant's last known address, as shown on the accompanying
notice of motion.

[ ] c. The regular mail has not been returned by the U.S. Postal Service.

[ ] d. The regular mail has been returned by the U.S. Postal Service with the
following notation: .

[ ] e. The certified mail return receipt card has been signed for and returned to
me.

[ ] f. Though the certified mailing has been returned by the U.S. Postal Service,
it was not returned in a manner that would indicate that the defendant's address is not
valid. It was not returned with any of the following markings by the U.S. Postal
Service: "Moved, unable to forward," "Addressee not known," "No such
number/street," "Insufficient address," "Forwarding time expired," or in any other
manner that would indicate that service was not effected.

4. The defendant, , has failed to comply with (check one) [ ] the Order, [ ] the
information subpoena.

5. On , 20 , I served a true copy of my notice of motion for an order to enforce
litigant’s rights on defendant (check one) [ ] personally, [ ] by sending it simultaneously
by regular and certified mail, return receipt requested, at the address shown on the proof of
service at the conclusion of the Order to Enforce Litigant’s Rights.

6. Neither the regular mail nor the certified mail containing the notice of motion has
been returned by the U.S. Postal Service in a manner that would indicate that the defendant's
address is not valid. Neither the regular nor certified mail was returned marked "Moved,
unable to forward," "Addressee not known," "No such number/street," "Insufficient
address," "Forwarding time expired," or in any other manner that would indicate that service
was not effected.

7. On , 20 _ , the Court entered an Order to Enforce Litigant’s Rights when
defendant failed to appear on the return day of my motion for an order enforcing litigant's
rights.

8. On , 20 _ , I served a true copy of the Order to Enforce Litigant’s Rights on
defendant (check one) [ ] personally, [ ] by sending it simultaneously by regular and
certified mail, return receipt requested, at the address shown on the Proof of Service at the
conclusion of the Order to Enforce Litigant’s Rights.

9. Neither the regular mail nor the certified mail has been returned by the U.S. Postal
Service in a manner that would indicate that the defendant's address is not valid. Neither the
regular nor certified mail was returned marked "Moved, unable to forward," "Addressee not
known," "No such number/street," "Insufficient address," "Forwarding time expired," or in
any other manner that would indicate that service was not effected.

10. Ten days have passed since I served a copy of the Order to Enforce Litigant’s Rights
on defendant, and defendant has not complied with the (check one) [ ] information
subpoena, [ ] Order for Discovery.

11. I request that the Court issue a warrant for the arrest of the defendant.

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 willfully false, I am subject to punishment.

DATE: ___________________________________



[Note: Former Appendix XI-O adopted July 14, 1992, effective September 1, 1992; redesignated as
Appendix XI-P July 13, 1994, effective September 1, 1994; amended July 10, 1998, to be effective
September 1, 1998; amended July 28, 2004 to be effective September 1, 2004.]

Appendix XI-O - Order to Enforce Litigant's Rights

APPENDIX XI-O.
ORDER TO ENFORCE LITIGANT’S RIGHTS


FAILURE TO COMPLY WITH THIS ORDER MAY RESULT IN YOUR ARREST

Name:
SUPERIOR COURT OF NEW JERSEY
Address: LAW DIVISION, SPECIAL CIVIL PART
Telephone No.
County

Docket No. _____________________

, Plaintiff
CIVIL ACTION

v. ORDER TO ENFORCE
LITIGANT’S RIGHTS
, Defendant


This matter being opened to the court by ____________________ on plaintiff's motion
for an order enforcing litigant's rights and the defendant having failed to appear on the return
date and having failed to comply with the (check one) G order for discovery previously entered
in this case, G information subpoena;

It is on the ____________ day of ____________, 20_____, ORDERED and adjudged:

1. Defendant _______________________ has violated plaintiff's rights as a litigant;

2. Defendant _______________________ shall immediately furnish answers as required by
the (check one) G order for discovery, G information subpoena;

3. If defendant ______________________ fails to comply with the (check one) G order for
discovery, G information subpoena within ten (10) days of the certified date of personal
service or mailing of this order, a warrant for the defendant's arrest shall issue out of this
Court without further notice;

4. Defendant shall pay plaintiff=s attorney fees in connection with this motion, in the amount
of $ .


____________________________
, J.S.C.
PROOF OF SERVICE


On ____________, 20___, I served a true copy of this Order on defendant
_______________ (check one) 9 personally, 9 by sending it simultaneously by regular and
certified mail, return receipt requested to:

(Set forth address) _______________________________________________

________________________________________________

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 willfully false, I am subject to punishment.


Date: _______________________ _______________________________


[Note: Former Appendix XI-N adopted July 14, 1992, effective September 1, 1992; redesignated
as Appendix XI-O July 13, 1994, effective September 1, 1994; amended July 12, 2002 to be
effective September 3, 2002; amended July 28, 2004 to be effective September 1, 2004.]

Appendix XI-N - Certification in Support of Motion for Order Enforcing Litigant's Rights

Name:
Address:
Phone No.:

SUPERIOR COURT OF NEW JERSEY
) LAW DIVISION, COUNTY
) SPECIAL CIVIL PART
Plaintiff, )
vs. ) DOCKET NO.
)
) Civil Action
)
Defendant ) CERTIFICATION IN SUPPORT OF
) MOTION FOR ORDER ENFORCING
LITIGANT'S RIGHTS


The following certification is made in support of plaintiff's motion for an order enforcing litigant's rights:

1. I am the plaintiff or plaintiff's attorney in this matter.

2. On , 20 , plaintiff obtained judgment against the defendant, , for $ damages,
plus costs.

3. (Check all applicable boxes below)

G a. On , 20 , an Order was entered by this Court ordering defendant to appear at
on , , at .m. and make discovery on oath as to the defendant's property and on , 20 , a copy of the
Order was served upon (check one) G personally, G by sending it simultaneously by regular and
certified mail, return receipt requested to defendant's last known address as set forth.

G b. On , , I served an information subpoena and attached questions as permitted by the Rules of
Court on the defendant, , (check one) G personally, G by sending it simultaneously by regular and
certified mail, return receipt requested to defendant's last known address as set forth.

G c. The regular mail has not been returned by the U.S. Postal Service.

G d. The regular mail has been returned by the U.S. Postal Service with the following notation:
.

G e. The certified mail return receipt card has been signed for and returned to me.

G f. Though the certified mailing has been returned by the U.S. Postal Service, it was not returned in a manner
that would indicate that the defendant's address is not valid. It was not returned with any of the following markings by the
U.S. Postal Service: “Moved, unable to forward,” “Addressee not known,” “No such number/street,” “Insufficient
address,” “Forwarding time expired,” or in any other manner that would indicate that service was not effected.

4. has failed to comply with (check one) G the order, G the information subpoena.

5. I request that the Court enter an order enforcing litigant's rights.

6. On , 20 , I served copies of this motion and certification on (check one) G personally, G
by sending them simultaneously by regular and certified mail, return receipt requested to
(Name and address) .

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 willfully false, I am subject to punishment.


Date:

NOTICE OF MOTION FOR ORDER ENFORCING LITIGANT'S RIGHTS

NOTICE OF MOTION FOR ORDER ENFORCING LITIGANT'S RIGHTS
Name: SUPERIOR COURT OF NEW JERSEY
Address: LAW DIVISION: SPECIAL CIVIL PART
Telephone No.: ___________ COUNTY
DOCKET NO ________________
Plaintiff, CIVIL ACTION
v. Notice of Motion for Order
Defendant. Enforcing Litigant’s Rights
TO: ___________________________________. Defendant
PLEASE TAKE NOTICE that on __________. 19___ at ______ __.m, I will apply to the above-named court,
located at ___________________, New Jersey, for an Order:
(1) Adjudicating that you have violated the litigant's rights of the plaintiff by failure to comply with the
(check one) q order for discovery,
q information subpoena served upon you;
(2) Compelling you to immediately furnish answers as required by the (check one) q order for discovery, q
information subpoena;
(3) Directing that, if you fail to appear in court on the date written above, you shall be arrested by an Officer
of the Special Civil Part or the Sheriff and confined in the county jail until you comply with the (check
one)
q order for discovery, q information subpoena;
(4) Directing that, if you fail to appear in court on the date written above, you shall pay the plaintiff's attorney
fees in connection with this motion;
(5) Granting such other relief as may be appropriate.
If you have been served with an information subpoena, you may avoid having to appear in court by sending
written answers to the questions attached to the information subpoena to me no later than three (3) days before
the court date.
I will rely on the certification attached hereto.
Date: _________________
________________________________
Attorney for Plaintiff or Plaintiff, Pro Se

APPENDIX XI-L. INFORMATION SUBPOENA AND WRITTEN QUESTIONS

APPENDIX XI-L.
INFORMATION SUBPOENA AND WRITTEN QUESTIONS

IMPORTANT NOTICE--PLEASE READ CAREFULLY

FAILURE TO COMPLY WITH THIS INFORMATION SUBPOENA MAY
RESULT IN YOUR ARREST AND INCARCERATION

NAME: SUPERIOR COURT OF NEW JERSEY
ADDRESS: LAW DIVISION: SPECIAL CIVIL PART
_______________ COUNTY
TELEPHONE NO.: DOCKET NO.
Attorneys for:

Plaintiff CIVIL ACTION
INFORMATION SUBPOENA
-vs-

Defendant

THE STATE OF NEW JERSEY, to: ______________________________________________

Judgment has been entered against you in the Superior Court of New Jersey, Law Division, Special
Civil Part, _______ County, on _______, 20__, in the amount of $_______ plus costs, of which
$_______ together with interest from _______, 20__, remains due and unpaid.

Attached to this Information Subpoena is a list of questions that court rules require you to answer
within 14 days from the date you receive this subpoena. If you do not answer the attached questions
within the time required, the opposing party may ask the court to conduct a hearing in order to
determine if you should be held in contempt. You will be compelled to appear at the hearing and
explain your reasons for your failure to answer.

If this judgment has resulted from a default, you may have the right to have this default judgment
vacated by making an appropriate motion to the court. Contact an attorney or the clerk of the court
for information on making such a motion. Even if you dispute the judgment you must answer all of
the attached questions.

You must answer each question giving complete answers, attaching additional pages if necessary.
False or misleading answers may subject you to punishment by the court. However, you need not
provide information concerning the income and assets of others living in your household unless you
have a financial interest in the assets or income. Be sure to sign and date your answers and return
them to the address in the upper left hand corner within 14 days.

Dated: _______, 20__

___________________________________ ___________________________________
Attorney for Clerk



QUESTIONS FOR INDIVIDUALS

1. Full name _______________________________________________________________

2. Address ________________________________________________________________

3. Birthdate ________________________________________________________________

4. Social Security # _________________________________________________________

5. Driver's license # and expiration date _________________________________________
_______________________________________________________________________

6. Telephone # _____________________________________________________________

7. Full name and address of your employer _______________________________________
_______________________________________________________________________
(a) Your weekly salary: Gross _______ Net _______
(b) If not presently employed, name and address of last employer. _________________
____________________________________________________________________

8. Is there currently a wage execution on your salary?
Yes ___ No ___

9. List the names, addresses and account numbers of all bank accounts on
which your name appears.

10. If you receive money from any of the following sources, list the amount,
how often, and the name and address of the source:

Type Amount & Frequency Name & Address of Sources
Alimony
Loan Payments
Rental Income
Pensions
Bank Interest
Stock Dividends
Other

11. Do you receive any of the following, which are exempt from levy? Any levy on
disclosed exempt funds may result in monetary penalties including reimbursement of
the debtor’s out-of-pocket expenses.

Social Security benefits Yes Amount per month No

S.S.I. benefits Yes Amount per month No

Welfare benefits Yes Amount per month No

V.A. benefits Yes Amount per month No

Unemployment benefits Yes Amount per month No

Workers’ compensation benefits Yes Amount per month No

Child support payments Yes _ Amount per month No

Attach copies of the three most recent bank statements for each account listed in
Question 9 that contains funds from these sources.

12. Do you own the property where you reside?
Yes ___ No ___ If yes, state the following:
(a) Name of the owner or owners ___________________________________ ____
(b) Date property was purchased ___ ________________________________ ____
(c) Purchase price _______________________________________________ _____
(d) Name and address of mortgage holder ____________________________ __
__________________________________________________________ _______
(e) Balance due on mortgage _____________________________________ ______

13. Do you own any other real estate?
Yes ___ No ___ If yes, state the following for each property:
(a) Address of property _____________________________________________ __
(b) Date property was purchased ___________________________________ ____
(c) Purchase price ________________________________________________ ____
(d) Name and address of all owners ________________________________ ____
__________________________________________________________ _______
(e) Name and address of mortgage holder ___________________________ ____
___________________________________________________________ ______
(f) Balance due on mortgage _______________________________________ ____
____________________________________________________________ _____
(g) Names and address of all tenants and monthly rental paid by each
tenant _____________________________________________________________
__________________________________________________________________


14. Does the present value of your personal property, which includes
automobiles, furniture, appliances, stocks, bonds, and cash on hand,
exceed $1,000?
Yes ___ No ___ If the answer is "yes," you must itemize all
personal property owned by you.
Cash on hand: $___________

Other personal property: (Set forth make, model and serial number. If
financed, give name and address of party to whom payments are made).

If Financed Present
Item Date Purchased Purchase Price Balance Still Due Value


15. Do you own a motor vehicle?
Yes ___ No ___ If yes, state the following for each vehicle owned:
(a) Make, model and year of motor vehicle ____________________________ _
________________________________________________________ _________
(b) If there is a lien on the vehicle, state the name and address of
the lienholder and the amount due to the lienholder _________ ____
_____________________________________________________________ ____
(c) License plate # ____________________________________________ _______
_________________________________________________________ ________
(d) Vehicle identification # _____________________________________ _____
___________________________________________________________ ______

16. Do you own a business?
Yes ___ No ___ If yes, state the following:
(a) Name and address of the business _______________________________ ___
________________________________________________________ _________
(b) Is the business a Corporation _______, sole proprietorship _______
or partnership _______?
(c) The name and address of all stockholders, officers and/or partners
_______________________________________________________ __________
________________________________________________________ _________
(d) The amount of income received by you from the business during the
last twelve months _________________________________________ _____
__________________________________________________________ _______

17. Set forth all other judgments that you are aware of that have been
entered against you and include:
Creditor's Creditor's Amount Name of
Name Attorney Due Court Docket #




I 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: ____________________ ___________________________________



QUESTIONS FOR BUSINESS ENTITY



1. Name of business including all trade names. _________________________ _____
_______________________________________________________________________
2. Addresses of all business locations. _______________________________ ______
_______________________________________________________________________
3. If the judgment-debtor is a corporation, the names and addresses of all
stockholders, officers and directors.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4. If a partnership, list the names and addresses of all partners.
_______________________________________________________________________
_________________________________________________________________ ____
_______________________________________________________________________
5. If a limited partnership, list the names and addresses of all general
partners.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
6. Set forth in detail the name, address and telephone number of all
businesses in which the principals of the judgment-debtor now have an
interest and set forth the nature of the interest.
_______________________________________________________________________

7. For all bank accounts of the judgment-debtor business entity, list the
name of the bank, the bank's address, the account number and the name in
which the account is held.
_______________________________________________________________________
_______________________________________________________________________
8. Specifically state the present location of all books and records of the
business, including checkbooks. ____________________________________ ____
_______________________________________________________________________
9. State the name and address of the person, persons, or entities who
prepare, maintain and/or control the business records and checkbooks.
________________________________________________________________________
_______________________________________________________________________
10. List all physical assets of the business and their location. If any asset
is subject to a lien, state the name and address of the lienholder and
the amount due on the lien.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
11. Does the business own any real estate? Yes ___ No ___
If yes, state the following for each property:
(a) Name(s) in which property is owned ____________________________ ______
(b) Address of property _______________________________________ __________
(c) Date property was purchased ____________________________________ _____
(d) Purchase price _______________________________________________ _______
(e) Name and address of mortgage holder ___________________________ ______
__________________________________________________________ _________
(f) Balance due on mortgage _____________________________________ ________
(g) The names and addresses of all tenants and monthly rentals paid by
each tenant.

NAME AND ADDRESS OF TENANT MONTHLY RENTAL

12. List all motor vehicles owned by the business, stating the following for
each vehicle:
(a) Make, model and year ____________________________________________ ____
_______________________________________________________________ ____
(b) License plate number _____________________________________________ ___
(c) Vehicle identification number ____________________________________ ___
(d) If there is a lien on the vehicle, the name and address of the
lienholder and the amount due on the lien
___________________________________________________________ ________
____________________________________________________________ _______
13. List all accounts receivable due to the business, stating the name,
address and amount due on each receivable.
NAME AND ADDRESS AMOUNT DUE

14. For any transfer of business assets that has occurred within six months
from the date of this subpoena, specifically identify:
(a) The nature of the asset __________________________________________ ___
___________________________________________________________________
(b) The date of transfer ____________________________________________ __ __
(c) Name and address of the person to whom the asset was transferred ___ _
___________________________________________________________________
(d) The consideration paid for the asset and the form in which it was
paid (check, cash, etc.) ____________________________________ ______
(e) Explain in detail what happened to the consideration paid for the
asset ________________________________________________________ _____
___________________________________________________________________
15. If the business is alleged to be no longer active, set forth:
(a) The date of cessation _________________________________________ ______
(b) All assets as of the date of cessation ___________________________ ___
___________________________________________________________________
(c) The present location of those assets ____________________________ ____
___________________________________________________________________
(d) If the assets were sold or transferred, set forth:

(1) The nature of the assets _________________________________ ______
_____________________________________________________ _________
(2) Date of transfer _________________________________________ ______
(3) Name and address of the person to whom the assets were
transferred _______________________________________________ ___
___________________________________________________________ ___
(4) The consideration paid for the assets and the form in which it
was paid ____________________________________________ _________
______________________________________________________ ________
(5) Explain in detail what happened to the consideration paid for
the assets ______________________________________________ _____
______________________________________________________ _ ______

16. Set forth all other judgments that you are aware of that have been entered
against the business and include the following:
Creditor's Creditor's Amount Due Name of Docket
Name Attorney Court Number

17. For all litigation in which the business is presently involved, state:
(a) Date litigation commenced ______________________________________ ____
(b) Name of party who started the litigation _______________________ _____
_________________________________________________________________
(c) Nature of the action ____________________________________________ ____
__________________________________________________________________
(d) Names of all parties and the names, addresses and telephone numbers
of their attorneys ____________________________________________________
__________________________________________________________________
__________________________________________________________________
(e) Trial date __________________________________________________________
(f) Status of case _______________________________________________________
(g) Name of the court and docket number ___________________________________
__________________________________________________________________
18. State the name, address and position of the person answering these
questions. ____________________________________________________________
____________________________________________________________________

I 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: ________________________ _________________________________


[Note: Former Appendix XI-K adopted June 29, 1990, effective September 4, 1990;
amended July 14, 1992, effective September 1, 1992; redesignated as Appendix XI-L and
amended July 13, 1994, effective September 1, 1994; amended July 28, 2004 to be effective
September 1, 2004.]