Confidential Litigant Information Sheet {10486}

New Jersey Judiciary 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 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 Please complete the entire form, leaving no blank spaces. If something does not apply to you, enter "N/A". This form is confidential and will not be shared with the other party. Docket Number: CS Number: Do you have an active Domestic Violence Order with the other party in this case? Yes No Plaintiff Name (last, first, middle initial) Social Security Number Address: Street City Plaintiff Telephone Number State Zip Date of Birth Place of Birth Defendant Name (last, first, middle initial) Social Security Number Address: Street City Defendant Telephone Number State Zip Date of Birth Place of Birth Employer Telephone Number Employer Telephone Number Employer Name (or other income source) Employer Address: Street City Professional, Occupational, Recreational Licenses (include types and license numbers) Employer Name (or other income source) Employer Address: Street State Zip City Professional, Occupational, Recreational Licenses (include types and license numbers) State Zip Driver's License Number Sex Race/Ethnicity State State of Issuance Height Make Weight Eyes Hair Year Driver's License Number Sex Race/Ethnicity State State of Issuance Height Make Weight Eyes Hair Year Auto: License Plate Attorney Name Attorney Address: Street City Model Auto: License Plate Attorney Name Attorney Address: Street Model State Zip City State Zip Children Information Name (last, first, middle initial) 1. 2. 3. 4. Date of Birth Race Sex Social Security Number Place of Birth Health Coverage for Children - available through parent filling out this form ( Health Care Provider: Health Care Provider: Health Care Provider: Policy Number: Policy Number: Policy Number: Plaintiff / Defendant) Group Number: Group Number: Group Number: I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if any of the foregoing statements made by me are wilfully false, I am subject to punishment. Date Revised: 10/2012, CN 10486 Signature page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com