Status, LLC: Civil Case Information Statement

CIVIL CASE INFORMATION STATEMENT

Use for initial Law Division Civil Part pleadings (not motions) under Rule 4:5-1
Pleading will be rejected for filing, under Rule 1:5-6(c), if information above the black bar is not completed
or if attorney's signature is not affixed.

ATTORNEY/PRO SE NAME	TELEPHONE NUMBER
FIRM NAME (if applicable)
OFFICE ADDRESS

COUNTY OF VENUE

DOCKET NUMBER (When available)

DOCUMENT TYPE

JURY DEMAND
YES NO

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

CAPTION

CASE TYPE NUMBER

If you believe this case requires a track other than provided, please indicate the reason under "case characteristics" below.

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

NONE UNKNOWN

THE INFORMATION 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	OTHER (explain below)
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 ACCOMODATIONS? YES NO	IF YES, PLEASE IDENTIFY THE REQUESTED ACCOMMODATION:
WILL AN INTERPRETER BE NEEDED? YES NO	IF YES, FOR WHAT LANGUAGE:

PLEASE CHECK OFF EACH APPLICABLE CATEGORY:
VERBAL THRESHOLD	PUTATIVE CLASS ACTION	TITLE 59

ATTACH SIGNATURE FILE:

Please make sure information is complete and accurate before clicking the Submit button below.