REQUEST FOR JUDICIAL INTERVENTION WORKSHEET

(New York Supreme/County Court – RJI UCS-840 shadow)

[// GUIDANCE: Use this to gather data before completing the official RJI (UCS-840) and NYSCEF fields.]

1. CAPTION

text
SUPREME COURT OF THE STATE OF NEW YORK
[COUNTY]

[PLAINTIFF/PETITIONER NAME], Plaintiff/Petitioner,
v. Index No.: [INDEX]
[DEFENDANT/RESPONDENT NAME], Defendant/Respondent.

2. NATURE OF ACTION OR PROCEEDING (RJI categories)

• Commercial: [ ] Business Entity [ ] Contract [ ] Insurance [ ] UCC [ ] Other Commercial
• Real Property: [ ] Condemnation [ ] Mortgage Foreclosure [ ] Partition [ ] Property Tax Certiorari [ ] Other Real Property
• Torts: [ ] Medical Malpractice [ ] Motor Vehicle [ ] Products Liability [ ] Other Negligence
• Special Proceedings: [ ] CPLR Article 75 (Arbitration) [ ] CPLR Article 78 [ ] Election Law [ ] Habeas Corpus [ ] Other Special Proceeding
• Other Matters: [DESCRIBE]

3. NATURE OF JUDICIAL INTERVENTION REQUESTED (RJI-style)

• [ ] Motion / OSC [ ] Preliminary Conference [ ] Note of Issue [ ] Settlement Conference [ ] Other: [DESCRIBE]
• Issue joined? [ ] Yes [ ] No

4. ADDENDA / DESIGNATIONS

• Commercial Division addendum required? [ ] Yes [ ] No
• Foreclosure addendum required? [ ] Yes [ ] No
• Matrimonial addendum required? [ ] Yes [ ] No
• Partition addendum required? [ ] Yes [ ] No

5. PARTIES & COUNSEL

• Plaintiff/Petitioner(s): [NAME / ADDRESS / PHONE / EMAIL]
• Defendant/Respondent(s): [NAME / ADDRESS / PHONE / EMAIL]
• Additional parties: attach list if needed.
• Attorney: [NAME], NY Bar [NUMBER], Firm: [FIRM], Address: [ADDRESS], Phone: [PHONE], Email: [EMAIL]
• [ ] Self-represented party

6. RELIEF / AMOUNT (worksheet)

• Monetary relief: $[AMOUNT] (exclusive of fees/costs)
• Non-monetary / equitable relief: [DESCRIBE]

7. JURY DEMAND

• [ ] Jury requested
• [ ] Non-jury

8. RELATED CASES (RJI-style)

• [ ] Yes (list court/Index No.): [DETAILS]
• [ ] No

9. SERVICE & SPECIAL NOTES (worksheet)

• Service addresses and method (sheriff/process server/certified mail): [DETAILS]
• Interpreter needed: [YES/NO] – Language: [SPECIFY]
• Accommodation needed (ADA/disability): [YES/NO] – Describe: [SPECIFY]

10. SIGNATURE

text
Date: [DATE]

____________________________________
[ATTORNEY NAME], NY Bar [NUMBER] / Pro Se
Attorney for [PARTY]
[// GUIDANCE: File the official RJI (UCS-840) with required addenda and NYSCEF information. Supply the correct nature-of-action category, intervention requested, and related-case details.]***