Confidential Litigant Information Sheet (New Jersey)
This form is a litigation information sheet (New Jersey). The form provided here is simply a sample of what the actual form looks like.
Confidential Litigant Information Sheet
To Assure Accuracy of Court Records
To be filled out by plaintiff or defendant or attorney
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?
Active Domestic Violence Order in this case? ____ Yes or ____ no
Social Security Number _________________________________
Date of Birth _________________________________
Place of Birth _________________________________
Driver's License Number (state of issuance) _________________________
Address _________________________________
Telephone Number _________________________________
Employer Name and Address (or other income source) _________________________________
Telephone Number _________________________________
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 _________________________________
Policy # _________________________________
Group # _________________________________
Dental Care Provider _________________________________
Policy # _________________________________
Group # _________________________________
Prescription Drug Provider _________________________________
Policy # _________________________________
Group# _________________________________
Children Information
Name (last, first, middle initial) _________________________________
Date of Birth _________________________________
Race _________________________________
Sex _________________________________
Social Security Number _________________________________
Place of Birth _________________________________
Name (last, first, middle initial) _________________________________
Date of Birth _________________________________
Race _________________________________
Sex _________________________________
Social Security Number _________________________________
Place of Birth _________________________________
Name (last, first, middle initial) _________________________________
Date of Birth _________________________________
Race _________________________________
Sex _________________________________
Social Security Number _________________________________
Place of Birth _________________________________
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 willfully false, I am subject to punishment.
_____________________________
Signature
_____________________________
Date
Note: Form adopted July 28, 2004 to be effective September 1, 2004; amended June 15, 2007 to be effective September 1, 2007.