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CIVIL-LAW Name Change – Minor 8/16/2006

HOW TO USE THIS ONLINE

This form can be filled out on screen, saved to your local drive, and printed out on your local printer or it can be printed out on your local printer for completion by hand or typewriter.

The information you enter is NOT

submitted electronically.

PAGE 1 Revised 09/2006, CN 10552-English


HOW TO ASK THE COURT TO CHANGE THE NAME OF YOURMINOR CHILD UNDER THE AGE OF 18

(Superior Court of New Jersey - Law Division - Civil Part)

WHO SHOULD USE THIS PACKET?

You can use this packet to ask for a court order to change the name of your child if your child is under the age of 18.

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

SEND YOUR COMPLETED FORMS TO:



THINGS TO THINK ABOUT BEFORE YOU TRY

TO REPRESENT YOURSELF IN COURT

TRY TO GET A LAWYER

The court system can be confusing and it is a good idea to get a lawyer if you can. The law, the proofs necessary to present your case, and the procedural rules governing cases in the Law Division, Civil Part are complex. Since valuable claims or potentially heavy judgments may be at stake, most litigants appearing in the Law Division, Civil Part have a lawyer. If you are being sued, please contact your insurance company to see if they might provide a lawyer for you. Most likely your opponent will be represented by a lawyer. It is recommended that you make every effort to obtain the assistance of a lawyer. If you cannot afford a lawyer, you may contact the legal services program in your county to see if you qualify for free legal services. Their telephone number can be found in your local yellow pages under “Legal Aid” or “Legal Services.” If you do not qualify for free legal services and need help in locating an attorney, you can contact the bar association in your county. That number can also be found in your local yellow pages. Most county bar associations have a Lawyer Referral Service. The County Bar Lawyer Referral Service can supply you with the names of attorneys in your area willing to handle your particular type of case and will sometimes consult with you at a reduced fee. There are also organizations of minority lawyers throughout New Jersey, as well as organizations of lawyers who handle specialized types of cases. Ask your county court staff for a list of lawyer referral services that include these organizations. If you decide to proceed without an attorney, these materials explain the procedures that must be followed to have your papers properly filed and considered by the court. These materials do not provide information on the law governing your claims or defenses; information on how to conduct pretrial discovery; information on alternative dispute resolution procedures, such as arbitration or mediation, that may be available or required in your case; information on the

kinds of evidence you need to prove your claims or defense at trial; or information on other procedural and evidentiary rules governing civil law suits. WHAT YOU SHOULD EXPECT IF YOU REPRESENT YOURSELF While you have the right to represent yourself in court, you should not expect special treatment, help or attention from the court. The following is a list of some things court staff can and cannot do for you. Please read it carefully before asking court staff for help. − We can explain and answer questions about

how the court works. − We can tell you what the requirements are to

have your case considered by the court. − We can give you some information from

your case file. − We can provide you with samples of court

forms that are available. − We can provide you with guidance on how

to fill out forms. − We can usually answer questions about

court deadlines. − We cannot give you legal advice. Only your

lawyer can give you legal advice. − We cannot tell you whether or not you

should bring your case to court. − We cannot give you an opinion about what

will happen if you bring your case to court. − We cannot recommend a lawyer, but we can

provide you with the telephone number of a local lawyer referral service.

− We cannot talk to the judge for you about what will happen in your case.

− We cannot let you talk to the judge outside of court.

− We cannot change an order issued by a judge.

KEEP COPIES OF ALL PAPERS Make and keep copies of all completed forms and documents related to your case.



OVERVIEW

The following is a brief overview of the process for having your child’s name changed by a court. The details follow. There are three basic steps that you must take to have your child’s name changed by the court: 1. You must fill out forms to send to the court with a filing fee. (If you are changing the names of

multiple family members, there is only one fee.) The forms are contained in this packet and include a complaint, an order fixing the date of hearing, a final judgment and a case information statement.

2. When the court returns the complaint and the order fixing the date of hearing to you, the forms will contain a docket number and will tell you in what newspaper you must publish the date of hearing. You must contact the newspaper to have the order fixing the date for the hearing published at least two weeks before the hearing date, and you must notify other interested parties. You will have to provide the court with proof that the appropriate parties have been notified of your intent to change your child’s name.

3. After you appear in court at the hearing, you will have to publish the final judgment in the newspaper and send copies of the certified final judgment to the Department of Treasury and the Registrar of Vital Statistics. If your child has a driver’s license, you will have to notify the Division of Motor Vehicles as well.

DEFINITIONS OF WORDS USED IN THIS PACKET

Affidavit of Publication - An affidavit of publication is a sworn statement made by a newspaper stating that the newspaper has published the information regarding your name change. Certification - A certification is a written statement you make when you file your papers with the court in which you state that all the information contained in the papers is true to the best of your knowledge. Civil Case Information Statement (CIS) The CIS is a form that summarizes your case for the court. Court rules require that a CIS be filed with a verified complaint. Docket Number - A docket number is the number the court assigns to your case so that it may be identified and located easily. Once you have a docket number, you must include it on all your communications with the court. File - To file means to give the appropriate forms and fee to the court to begin the court’s consideration of your case. Final Judgment - The final judgment is a document signed by the judge which orders the name to be changed. Order Fixing Date of Hearing - An order fixing the date of hearing is a signed paper from the judge indicating the date when you must come to court on your case and stating the name of the newspaper in which you will have to publish your hearing date. Proof of Mailing - Proof of mailing is the green card you get back from the Post Office that proves that the material you sent by certified mail, return receipt requested, was received by the person to whom you sent it. Verified Complaint - A verified complaint is a document in which you tell the court the facts of your case and state what relief you want the court to give you. You certify that the information is true to the best of your knowledge.



The numbered steps listed below tell you what forms you will need to fill out and what to do with them. Each form should be typed or printed clearly on 8 ½ “x 11” white paper only. Forms may not be filed on a different size or color paper.

STEPS TO OBTAIN A COURT ORDER TO CHANGE THE NAME OF YOUR CHILD

STEP 1: FILL OUT THE VERIFIED COMPLAINT (Form A).

The Verified Complaint (Form A) tells the court what your child’s name is, what you want to change it to, and why you want it changed. If your child has ever been convicted of a crime, or if there are charges pending against your child, you must include this information in your Verified Complaint. You must sign the certification which states that the information in the complaint is true to the best of your knowledge. STEP 2: FILL OUT THE ORDER FIXING DATE OF HEARING AND THE FINAL JUDGMENT FORMS (Forms B and C).

Enter the information requested. Note that there are places on the Order Fixing Date of Hearing and Final Judgment that the court will complete. STEP 3: FILL OUT THE CIVIL CASE INFORMATION STATEMENT (CIS) (Form F).

This form summarizes your case for the court. The case type number for a name change is 151. STEP 4: MAKE A CHECK OR MONEY ORDER PAYABLE TO TREASURER, STATE OF NEW JERSEY IN THE AMOUNT OF $200.00.

This is the fee for filing your papers.

Note: If you are changing the names of multiple family members, the $200.00 fee covers all name change applications.

STEP 5: CHECK YOUR COMPLETED FORMS AND MAKE COPIES.

Check your forms and make sure they are complete. Remove all instruction sheets. Make sure you have signed all the forms wherever necessary. You also need to make three copies of each form. Two of the copies will be sent to the court; the other is for your records.

Checklist - In Step 6 you will be directed to mail your documents to the court. The following checklist will help insure your package is complete: − The original of each of the forms you filled

out: Verified Complaint (Form A), Order Fixing Date of Hearing(Form B), Final Judgment (Form C) and the Civil Case Information Statement (Form F)

− Two copies of each of these forms: Verified Complaint, Order Fixing Date of Hearing, Final Judgment and the Civil Case Information Statement.

− The filing fee in the amount of $200. It must be a check or money order payable to the Treasurer, State of New Jersey.

− A stamped envelope addressed to yourself so that the court will be able to return the forms to you.

STEP 6: MAIL OR DELIVER THE FORMS TO THE COURT.

You may mail or deliver to the court the original and 2 copies of all the forms: Verified Complaint (Form A), Order Fixing Date of Hearing(Form B), Final Judgment (Form C) and the Civil Case Information Statement (Form F) along with the self addressed envelope and the filing fee. The court address can be found on the front of this packet or on the Judiciary’s website, www.njcourtsonline.com. If you mail the papers, we recommend that you use certified mail, return receipt requested.



PAGE 6

STEP 7: REVIEW COPIES RETURNED FROM COURT.

The court will return copies of the Verified Complaint and Order Fixing Date of Hearing to you. Once you receive them, there will be a docket number written on all the copies. The docket number is very important because it identifies your case. It also lets the court know how to find your case. You must use the docket number on all future papers you send to the court about your case. The court will fill in the date on the Order Fixing Date of Hearing. That is the day you will appear before the judge to get the final judgment. The court will also indicate the name of a newspaper in which you are to have the notice of your hearing date published. IF YOUR CHILD DOES NOT HAVE PENDING CRIMINAL OR DELINQUENT CHARGES IN NEW JERSEY, SKIP TO STEP 9. STEP 8: IF YOUR CHILD HAS CRIMINAL OR DELINQUENT CHARGES PENDING, NOTIFY THE COUNTY PROSECUTOR OF YOUR APPLICATION FOR A NAME CHANGE.

If your child has criminal or delinquent charges pending in New Jersey, you must send a copy of the Verified Complaint and Order Fixing Date of Hearing by certified mail, return receipt requested, to the Prosecutor of the county where the matter is being heard. Your post office can tell you how to do this. STEP 9: PUBLISH THE ORDER FIXING DATE OF HEARING.

In the Order Fixing Date of Hearing that you receive back from the court, the judge will have specified the name of a local newspaper. You must have the Order Fixing Date of Hearing published in the newspaper the judge chooses. It must be published in the newspaper at least two (2) weeks before the date of the hearing. You should talk to the newspaper about how to publish legal notices. Included in this packet as Attachment E is a sample of the newspaper notice.

STEP 10: SEND AFFIDAVIT OF PUBLICATION TO THE COURT.

Once you have published the Order Fixing Date of Hearing, the newspaper will send you an affidavit of publication, which is proof that you had the newspaper publish the Order Fixing Date of Hearing. You must send the original of this affidavit of publication document to the court immediately after you get it from the newspaper. Keep a copy of it for your files. STEP 11: NOTIFY MINOR CHILD’S OTHER PARENT.

If you are changing the name of a child who is under the age of 18 years and the child’s other parent does not reside with you, you must send a copy of the Verified Complaint and the Order Fixing Date for Hearing to the last known address of the child’s other parent. This must be sent by certified mail, return receipt requested. Your post office can tell you how to do this. STEP 12: COMPLETE PROOF OF MAILING (FORM D) AND SEND TO COURT.

After you have mailed the required copies of the Verified Complaint and signed Order Fixing Date for Hearing, the post office will send you a green card (called a certified mail receipt) that shows the mail was delivered. Once you get it back, fill out the form called Proof of Mailing (Form D) and check each entity to whom you sent a copy of the complaint and order. Be sure to attach the original green certified mail receipt(s) to the original proof of mailing. Send the proof of mailing to the court. Keep a copy of it for your files. STEP 13: APPEAR IN COURT ON THE DATE SET BY THE JUDGE FOR YOUR HEARING. STEP 14: PUBLISH THE FINAL JUDGMENT IN THE NEWSPAPER.

After the hearing, the court will record the original Final Judgment signed by the judge. However, the newspaper published version shall

Revised 09/2006, CN 10552-English


Department of Treasury not include the child’s social security number.

As soon as you receive your copy of the Final Judgment, you must send it to be published in the newspaper chosen by the judge. The Final Judgment must appear in the newspaper no more than 20 days after the date on the judgment. After you have it published, the newspaper will send you an original affidavit of the publication.

Division of Revenue Judgment Name Change Unit

P. O. Box 453 Trenton, NJ 08646

STEP 18: NOTIFY THE REGISTRAR OF VITAL STATISTICS OF THE STATE.

You should send a copy of the certified Final Judgment to the Registrar of Vital Statistics of the State in which your child was born. You can locate the address of that office by contacting them by telephone. Directory assistance can provide you with the telephone number of that office. They are located in the capital city of the State in which your child was born. That office will tell you if there is a filing fee. If your child was born in New Jersey, the address for this office is:

STEP 15: SEND THE AFFIDAVIT OF PUBLICATION TO THE COURT.

You must send the original affidavit of publication to the court at the address found on the front of this packet within 45 days after the date of the judgment. STEP 16: ORDER A CERTIFIED COPY OF FINAL JUDGMENT.

You must order from the court a certified copy of the Final Judgment, by mail or in person. There is no charge for the first certified copy. Additional copies can be ordered for $5.00 each. Keep this for your files. Copies of the certified Final Judgment must be sent to the Department of Treasury (Step 17), the Registrar of Vital Statistics (Step 18). If your child has a driver’s license, you must present the Final Judgment in person at any Motor Vehicle Agency or Regional Service Center (Step 19).

Bureau of Vital Statistics P. O. Box 370

Trenton, NJ 08625

In New Jersey there is also a $27.00 fee if you want to receive a corrected birth certificate. STEP 19: NOTIFY THE MOTOR VEHICLES COMMISSION. If your child is a licensed driver, a registered owner of a vehicle, or possesses a handicapped or non-driver identification card, you must present the Final Judgment in person at any Motor Vehicle Agency or Regional Service Center within two weeks of the date of the Final Judgment. Additional information is available at the MVC web site at www.njmvc.gov regarding the list of acceptable documents to satisfy the 6 points of identification.

STEP 17: SEND COPY OF CERTIFIED FINAL JUDGMENT TO THE DEPARTMENT OF TREASURY.

Mail a copy of the certified Final Judgment to the Department of Treasury within 45 days after the date of the Judgment. You must include a check or money order payable to the Treasurer, State of New Jersey in the amount of $50. Mail the copy of the certified Final Judgment with the check or money order and a stamped self-addressed envelope to:

++++++


http://www.njmvc.gov/

FORM A

PAGE 1

SUPERIOR COURT OF NEW JERSEY LAW DIVISION

County

Your Name (first, middle, last) Docket Number

(to be filled in by the court) Street Address

Town, State, Zip Code

Telephone Number

In the Matter of the Application of

Your Name (first, middle, last) To Change the Name of

Name of Minor Child (first, middle, last) To

Name You Wish Your Child To Assume (first, middle, last)

CIVIL ACTION

Verified Complaint

Including Certification For Name Change

of Minor Child

The plaintiff, , whose place of residence is (your name, first, middle, last) , in the City of (street address) County of , in the State of New Jersey, says: 1. I am the parent of , and make this application to (child’s name) change my child’s name to . (name you want your child to assume)

2. My child (check one) is □ is not □ a citizen of the United States of America. 3. My child’s social security number is - - . 4. My child was born on , in . (date, month, year) (place of birth)


FORM A

PAGE 2

5. My child’s other parent is named and lives at (full name of other parent)

. (other parent’s address)

6. My child is being raised by and .

7. Since birth, my child has been identified by the name of . (first, middle, last)

8. My child (check one) has □ has never □ been married.

9. There are no unsatisfied judgments of record, or suits pending against my child, except:

(enter any recorded judgments or pending suits)

10. My child has never been convicted of a crime or delinquent behavior, and has no criminal or

delinquent charges pending, except:

(please supply county, municipality, nature and date of crime)

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

other fraudulent purpose.

12. There (check one) have □ have not □ been any previous applications to assume another name.

13. I desire my child to assume the name of: . (first, middle, last)

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


FORM A

PAGE 3

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

Signature of Plaintiff

Certification I certify that the foregoing statements are true. I am aware that if any of the foregoing statements

made by me are wilfully false, I am subject to punishment.

Signature of Plaintiff

Dated:


FORM B

SUPERIOR COURT OF NEW JERSEYLAW DIVISION

County

Your Name (first, middle, last)

Street Address

Docket Number

(to be filled in by the court)


Telephone Number



To Change the Name of

Name of Minor Child (first, middle, last)

To


CIVIL ACTION

Order Fixing Date

Of Hearing

Application being made to the Court by , (your name, first, middle, last)

for a judgment authorizing (check one) □ his □ her minor child to assume another

name and for the entry of an order fixing a date for the hearing of such application,

DO NOT WRITE BELOW; THE COURT WILL FILL IN THE INFORMATION

IT IS ON THIS day of , 20 , ORDERED that

the day of , 20 , at

a.m., or as soon thereafter as the matter can be heard, at the Court House in the City

of , County of , State of New Jersey, be

fixed as the time and place for the hearing of such application and of any objections

that me be made thereto.


FORM B

IT IS FURTHER ORDERED that a notice of such application be published in

once, at least two (2) weeks preceding

the date set for the hearing.

, J.S.C. NOTE: Copies of the verified complaint and order fixing the date of the hearing

must be sent to the other parent of the minor child and to the newspaper for publication and served on the County Prosecutor if the minor has charges pending.


FORM C

PAGE 1

SUPERIOR COURT OF NEW JERSEYLAW DIVISION

County

Your Name (first, middle, last) (to be filled in by the court)

Street Address

Docket Number


Telephone Number



Name of Minor Child (first, middle, last)

To


CIVIL ACTION

Final Judgment

, having made application to this Court (your name, first, middle, last)

by duly verified complaint for a judgment authorizing (check one) □ his □ her child to assume the name of , and it appearing to (name you wish your child to assume) the Court that all the provisions of N.J.S.A. 2A:52-1-4 and the Current N.J. Court Rules

relating thereto have been complied with:

IT IS on this day of ,20 , (leave date blank for court to complete) ORDERED AND ADJUDGED that , who (your child’s name) was born on , and whose social security number is - - , (month, day, year ) (your child’s social security number) be and hereby is authorized to assume the name of from (name you wish your child to assume) and after ;and (leave date blank for court to complete)


FORM C

DO NOT WRITE BELOW THIS LINE; THE COURT WILL COMPLETE.

IT IS FURTHER ORDERED that within twenty days hereof plaintiff shall cause a

copy of this Final Judgment to be published once in____________________________;

and within forty-five days after entry of Judgment, plaintiff shall file proof of publication

of this Final Judgment with the deputy Clerk of the Superior Court (at the court address

found at the back of this packet for the court in which you filed your verified complaint)

and a certified copy of this Final Judgment with the Department of Treasury pursuant to

the provisions of the Statute and Rules in such case made and provided; and

IT IS FURTHER ORDERED that the published version of the final judgment shall

not release the minor child’s social security number.

J.S.C.

Dated: .

Page 2 Revised 09/2006, CN 10552-English

FORM D SUPERIOR COURT OF NEW JERSEY

LAW DIVISION

County


Docket Number

(to be filled in by the court) Street Address


Telephone Number



Name of Minor Child (first, middle, last) To


CIVIL ACTION

Proof of Mailing

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

Change of Name and Order Fixing Date of Hearing in accordance with the rules of Civil

Practice and Procedure, by certified United States Mail, return receipt requested to

(check and complete all that apply):

__ the Prosecutor of County

__ the non-party parent of the minor child at his or her last known address

NOTE: The green return mail receipt(s) are attached.

I certify that the foregoing statements made by me are true. I am aware that if any of

the foregoing statements made by me are wilfully false, I am subject to punishment.

, Your Signature Dated: .


Attachment E

SAMPLE NEWSAPER NOTICE IN THE MATTER OF THE APPLICATION OF , Your name (first, middle, last) TO CHANGE THE NAME OF . Name of your minor child (first, middle, last) TO , Name you want your child to assume (first, middle, last) TO WHOM IT MAY CONCERN: Take notice that the undersigned will apply to (county where name change action is filed) County Superior Court on the day of 20 , at

9 o’clock in the morning, at the Court House in the City of . (name of city) New Jersey, for a judgment authorizing __________________________ to assume the (name of child, first middle, last) name of _________________________________________________. (name you wish your child to assume, first, middle, last)

Your Name (first, middle, last) Street Address



CIVIL – LAW – 7/26/2006 CASE INFORMATION STATEMENT – FORM F

HOW TO COMPLETE THE CIVIL CASE INFORMATION STATEMENT (CIS)

These instructions are intended to guide individuals who are either plaintiffs or defendants in civil cases and who are not represented by an attorney in completing the Civil Case Information Statement (Civil CIS) required by court rules. The Civil CIS must be included with each party’s first pleading in the Civil part of the Law Division. That is, the plaintiff must file it with the complaint and the defendant must file it with the answer. If it is not included, the papers will be returned. The CIS summarizes your case and alerts the court to any special needs you may have such as the need for an interpreter or the need for a quick trial date because one of your witnesses is expected to be unavailable. The numbers for the various case types are located on the back of the form. Enter the number which best describes your complaint. For example, if you are suing the defendant for a breach of contract, your case number would be 599. After you have completed the CIS, keep it with the other papers you are planning to file.

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

PAGE 1 Revised 09/2006, CN 10517-EnglishHow to Ask the Court to Change Your Name (Minor), CN 10552-English


INSTRUCTIONS FOR PARTIES NOT REPRESENTED BY AN ATTORNEY FOR COMPLETING THE CIVIL CASE

INFORMATION STATEMENT (CIS) BOX# INSTRUCTION 1. Print your name. 2. List a telephone number, including area code, where you can be reached during

the day. 3. Insert the name of the county where the complaint or answer is being filed. 4, Leave the box blank. 5. If you know the docket number of your case, insert it in the docket number box.

If the CIS is being filed with a complaint, the court will assign the docket number before it returns the filed complaint.

6. Enter an address where you wish to receive mail concerning this matter. 7. Document type means the type of paper you are filing. If you are filing the

complaint, print complaint; if you are filing an answer, print answer. For a name change, you are filing a verified complaint.

8. Check the box marked “yes” if you have requested that the matter be heard by a jury. Otherwise, check “no.”

9. Enter your name and indicate whether you are the plaintiff or defendant. 10. The caption is the name of the case - the name of the plaintiff(s) v. the name of

the defendant(s). For the name change of a minor, the caption should be “In the Matter of the Application of (your name) to Change the Name of (child’s name) to (new name).

11. The Case Type Number identifies the type of case. On the back of the CIS form is a list of case types. The case type number for a name change is 151.

12. Check the box marked “no.” 13. If you believe that you have any other cases involving the same adversary or

arising from the same set of circumstances, check the box marked “yes.” Otherwise, check “no.”

14. If you checked “yes” to the previous question, enter the docket number(s) of any related cases.

15. If you believe you will be adding more parties to the case, check “yes.” Otherwise, check “no.”

16. If you are the plaintiff and know the name of the defendant’s primary insurance company enter it in the box. Otherwise check “unknown.” If you are the defendant and you have insurance that might cover or partially cover the damages complained of, enter the name of your insurance company.

17. If you and your adversary knew each other before the event giving rise to the law suit occurred, check “yes.” Otherwise, check “no.” If the answer was “yes”, check the box next to the word(s) that best describe the relationship between the parties.



18. If you believe that the statute governing your case provides for payment of fees by the losing party, (for example, the Law Against Discrimination), check “yes.” Otherwise, check “no.”

19. If you believe that your case has some unusual circumstance which would require special attention, indicate the problem in the space provided. For example, if there is a witness who is ill or who may be unavailable, you should let the court staff know.

20. If you are requesting any accommodation for a disability, check “yes” and indicate what is needed. Otherwise, check “no.”

21. If you are requesting an interpreter, check “yes” and indicate the language for which it is needed. Otherwise, check “no.”

22,. The person whose name appears in Box 1 must sign the CIS in the space marked “Attorney Signature.”


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:

1. ATTORNEY/PRO SE NAME

2. TELEPHONE NUMBER ( )

3. COUNTY OF VENUE

4. FIRM NAME (If applicable)

5. DOCKET NUMBER (When available)

7. DOCUMENT TYPE 6. OFFICE ADDRESS

8. JURY DEMAND YES NO

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

10. CAPTION

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

12. IS THIS A PROFESSIONAL MALPRACTICE CASE? YES NO IF YOU HAVE CHECKED “YES,” SEE N.J.S.A. 2A:53A-27 AND APPLICABLE CASE LAW REGARDING YOUR OBLIGATION TO FILE AN AFFIDAVIT OF MERIT.

13. RELATED CASES PENDING? YES NO

14. IF YES, LIST DOCKET NUMBERS

15. DO YOU ANTICIPATE ADDING ANY PARTIES (arising out of same transaction or occurrence)?

YES NO 16. 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

17. A. DO PARTIES HAVE A CURRENT, PAST OR RECURRENT RELATIONSHIP? YES NO

IF YES, IS THAT RELATIONSHIP

EMPLOYER-EMPLOYEE FRIEND/NEIGHBOR OTHER (explain) FAMILIAL BUSINESS

18. B. DOES THE STATUTE GOVERNING THIS CASE PROVIDE FOR PAYMENT OF FEES BY THE LOSING PARTY?

YES NO

19. USE THIS SPACE TO ALERT THE COURT TO ANY SPECIAL CASE CHARACTERISTICS THAT MAY WARRANT INDIVIDUAL MANAGEMENT OR ACCELERATED DISPOSITION:

20. DO YOU OR YOUR CLIENT NEED ANYDISABILITY ACCOMMODATIONS?

YES NO

IF YES, PLEASE IDENTIFY THE REQUESTED ACCOMMODATION:

21. WILL AN INTERPRETER BE NEEDED?

YES NO

IF YES, FOR WHAT LANGUAGE:

22. ATTORNEY SIGNATURE Revised 09/28/2006, CN 10517-English

How to Ask the Court to Change Your Name (Minor), CN 10552-English

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

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

Mass Tort (Track IV) 240 REDUX/PHEN-FEN (formerly "DIET DRUG") 271 ACCUTANE 241 TOBACCO 272 BEXTRA/CELEBREX 248 CIBA GEIGY 274 RISPERDAL/SEROQUEL/ZYPREXA 264 PPA 601 ASBESTOS 266 HORMONE REPLACEMENT THERAPY (HRT) 619 VIOXX 268 MANUFACTURED GAS PLANT (MGP)

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

SIDE 2

Revised 09/28/2006, CN 10517-EnglishHow to Ask the Court to Change Your Name (Minor), CN 10552-English


Directory of Civil Division Managers’ Offices

Below is a list of addresses and phone numbers for Civil Division Managers in every courthouse. You must send your papers to the county where you are filing your case. Use this list of addresses to find the appropriate Superior Court to file your papers. Civil Division Manager Civil Division Manager Atlantic County Civil Courts Building Bergen County Justice Center 1201 Bacharach Blvd. 10 Main Street, Room 415 Atlantic City NJ 08401 Hackensack, NJ 07601-7015 (609) 345-6700 (201) 527-2601

Civil Division Manager Civil Division Manager Burlington County Courts Facility Camden County 49 Rancocas Road Hall of Justice Mt. Holly NJ 08060 101 South Fifth Street, Suite 150 (609) 518-2815 Camden, NJ 08103 (856) 379-2234

Civil Division Manager Civil Division Manager Cape May County Superior Court Cumberland County Courthouse 4 Moore Road, DN 203 Broad and Fayette Streets Cape May Court House NJ 08210 Bridgeton NJ 08302 (609) 463-6515 (856) 453-4331

Civil Division Manager Civil Division Manager Essex County Superior Court Gloucester County Courthouse 470 Martin Luther King, Jr. Blvd. Broad and Delaware Streets Room 208 HCH Woodbury NJ 08096 Newark NJ 07102 (856) 853-3375 (973) 693-6521 Civil Division Manager Civil Division Manager Hudson County Superior Court Hunterdon Justice Center 583 Newark Avenue Hunterdon Civil Division Jersey City NJ 07306 65 Park Ave., 2nd Floor (201) 795-6398 Flemington NJ 08822 (908) 237-5832

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CIVIL-LAW Name Change – Minor 8/24/2006 Civil Division Manager Civil Division Manager Mercer County Civil Courts Building Middlesex County Courthouse 175 South Broad Street One John F. Kennedy Square Trenton NJ 08650-0068 P.O. Box 2633 (609) 571-4452 New Brunswick, NJ 08903 (732) 981-3055

Civil Division Manager Civil Division Manager Monmouth County Courthouse Morris County Courthouse 71 Monument Park P.O. Box 910 Freehold NJ 07728 Morristown NJ 07963-0910 (732) 677-4298 (973) 656-4110

Civil Division Manager Civil Division Manager Ocean County Justice Complex Passaic County Courthouse 120 Hooper Avenue 77 Hamilton Street Toms River NJ 08754 Paterson NJ 07525 (732) 929-2042 (973) 247-8176

Civil Division Manager Civil Division Manager Salem County Courthouse Somerset County 92 Market Street 40 North Bridge Street Salem NJ 08079 P.O. Box 3000 (856) 935-7510 Somerville NJ 08876 (908) 231-7054

Civil Division Manager Civil Division Manager Union County Courthouse Warren County Courthouse Two Broad Street 413 Second Street Elizabeth, NJ 07207 P.O. Box 900 (908) 659-3844 Belvidere NJ 07823 (908) 475-6143

Civil Division Manager Sussex County Judicial Center 7 High Street Newton, NJ 07860 (973) 579-0675

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