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    3B Confidential Litigant Information Sheet 2019

    Uploaded by

    chnhockey
    Confidential Litigant Information Sheet 2019

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    3B Confidential Litigant Information Sheet 2019

    Uploaded by

    chnhockey
    24 views1 page
    Confidential Litigant Information Sheet 2019

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Confidential Litigant Information Sheet 2019

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    24 views1 page

    3B Confidential Litigant Information Sheet 2019

    Uploaded by

    chnhockey
    Confidential Litigant Information Sheet 2019

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    PrintForm Clear form

    Form 3B: Confidential Litigant Information Sheet (CLIS)—Page 1 of 1


    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 Defendant
    Name (last, first, middle initial) Name (last, first, middle initial)

    Social Security Number Date of Birth Place of Birth Social Security Number Date of Birth Place of Birth

    Address: Street Address: Street

    City State Zip City State Zip

    Plaintiff Telephone Number Employer Telephone Number Defendant Telephone Number Employer Telephone Number

    Employer Name (or other income source) Employer Name (or other income source)

    Employer Address: Street Employer Address: Street

    City State Zip City State Zip

    Professional, Occupational, Recreational Licenses Professional, Occupational, Recreational Licenses


    (include types and license numbers) (include types and license numbers)

    Driver's License Number State of Issuance Driver's License Number State of Issuance

    Sex Race/Ethnicity Height Weight Eyes Hair Sex Race/Ethnicity Height Weight Eyes Hair

    Auto: License Plate State Make Model Year Auto: License Plate State Make Model Year

    Attorney Name Attorney Name

    Attorney Address: Street Attorney Address: Street

    City State Zip City State Zip

    Children Information
    Social Security
    Name (last, first, middle initial) Date of Birth Race Sex Number Place of Birth
    1.
    2.
    3.
    4.

    Health Coverage for Children - available through parent filling out this form ( Plaintiff / Defendant)
    Health Care Provider: Policy Number: Group Number:
    Health Care Provider: Policy Number: Group Number:
    Health Care Provider: Policy 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 Signature
    Revised: 10/2012, CN 10486 page 1 of 1
    Note: This form is available on the New Jersey Judiciary’s website at www.njcourts.gov/selfhelp.

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