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RULE 7:8-7(b) CERTIFICATION APPLICATION FOR APPOINTMENT AS PRIVATE PROSECUTOR

State of New Jersey vs. Docket Number(s): Charge(s): Attorney Information: Name: Address Telephone Number:

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

This Certification is supplied to the ____________________________________________________________________ Municipal Court, pursuant to the provisions of R. 7:8 -7(b) and State v. Storm, 141 N.J. 245 (1995) to provide the court and the prosecutor with all facts that may foreseeably affect the fairness of the proceedings to enable the court to determine whether I may be appointed as an impartial private prosecutor for________________________________ _______________________________________________, the complaining witness in the above matter. 1. (Please circle the applicable letter). The complaining witness is (a) an individual, (b) a business (please describe): _________________________________________________________________________________________________ or (c) an entity with its own police department (please describe): _______________________________________________ _________________________________________________________________________________________________ 2. There is no actual conflict of interest arising from my representation of, and fee arrangement with, the complaining witness. Check if correct. [ ] If not, please explain: _________________________________________________________________ _________________________________________________________________________________________________. 3. The municipal prosecutor has elected not to conduct the prosecution. Check if correct. [ ] If not, please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4. The defendant is or is expected to be represented by counsel. [ ] Yes defendant's attorney. [ ] Yes [ ] No [ ] No [ ] Unknown. Notice has been given to

5. There is no civil litigation, existing or anticipated, between the complaining witness and the defendant concerning the same or similar facts as are contained in the complaint. In the event of such civil litigation, I have informed the complaining witness that neither I nor any member of my firm will undertake the complaining witness' representation in that matter. Check if correct. [ ] If not, please explain: __________________________________________________________ ___________________________________________________________________________________________________ 6. There are no other facts that could reasonably affect the impartiality of the private prosecutor and the fairness of the proceedings or otherwise create an appearance of impropriety. Check if correct. [ ] If not, please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________. Comments: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please attach additional sheets, if necessary.

CERTIFICATION IN LIEU OF OATH 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

_________________________________________ Name of Applicant
(February, 1999)