Confidential Litigant Information Sheet (R. 5:4-2(g))
To Assure Accuracy of Court Records To be filled out by plaintiff or defendant or attorney
PrintForm
Clear form
Collection of the following information is pursuant to N.J.S.A. 2A:17-56.60 and R. 5:7-4. Confidentiality of this information must be maintained.
Docket # CS Your Name (last, first, middle initial):______________________________________________________________________________________________
Are You: Plaintiff or Defendant? (circle one) Active Domestic Violence Order in this case? Yes or no (circle one) Address Social Security Number Date of Birth Place of Birth Driver's License Number (state of issuance)
-
Telephone Number ( ) Telephone Number ( )
Employer Name and Address (or other income source)
Professional, Occupational, Recreational Licenses (Types and Numbers)
Attorney Name and Address
Health Coverage for Children (available through parent filling out this form) Health Care Provider Dental Care Provider Prescription Drug Provider Policy # Policy # Policy # Group # Group # Group#
Children Information
Name (last, first, middle initial) Date of Birth Race Sex Social Security Number Place of Birth
1. 2. 3. 4. 5. 6.
Sex
Race
Height
Weight
Eyes
Hair
Auto License Plate # (State of issuance)
Car (model, make, year)
Mother's maiden 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 wilfully false, I am subject to punishment. _____________________________ Date __________________________________ Signature
Note: Form adopted July 28, 2004 to be effective September 1, 2004; amended June 15, 2007 to be effective September 1, 2007.
Revised: 9/2007, CN: 10486-English