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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.

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