Form 10517 Appendix XII-B1 "Civil Case Information Statement (Cis)" - New Jersey

What Is Form 10517 Appendix XII-B1?

This is a legal form that was released by the New Jersey Superior Court - a government authority operating within New Jersey.The document is a supplement to Form 10517, Civil Case Information Statement (Cis) - Pro Se. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 23, 2020;
  • The latest edition provided by the New Jersey Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 10517 Appendix XII-B1 by clicking the link below or browse more documents and templates provided by the New Jersey Superior Court.

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Download Form 10517 Appendix XII-B1 "Civil Case Information Statement (Cis)" - New Jersey

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For Use by Clerk’s Office Only
Civil Case Information Statement
Payment type:
ck
cg
ca
(CIS)
Chg/Ck Number:
Use for initial Law Division
Amount:
Civil Part pleadings (not motions) under Rule 4:5-1
Pleading will be rejected for filing, under Rule 1:5-6(c),
Overpayment:
if information above the black bar is not completed
Batch Number:
or attorney’s signature is not affixed
Attorney/Pro Se Name
Telephone Number
County of Venue
Firm Name (if applicable)
Docket Number (when available)
Office Address
Document Type
Jury Demand
Yes
No
Name of Party (e.g., John Doe, Plaintiff)
Caption
Case Type Number
Are sexual abuse claims
Is this a professional malpractice case?
Yes
No
(See reverse side for listing)
alleged?
If you have checked “Yes,” see N.J.S.A. 2A:53A-27 and applicable case law
Yes
No
regarding your obligation to file an affidavit of merit.
Related Cases Pending?
If “Yes,” list docket numbers
Yes
No
Do you anticipate adding any parties
Name of defendant’s primary insurance company (if known)
(arising out of same transaction or occurrence)?
None
Yes
No
Unknown
The Information Provided on This Form Cannot be Introduced into Evidence.
Case Characteristics for Purposes of Determining if Case is Appropriate for Mediation
Do parties have a current, past or recurrent relationship?
If “Yes,” is that relationship:
Employer/Employee
Friend/Neighbor
Other (explain)
Yes
No
Familial
Business
Does the statute governing this case provide for payment of fees by the losing party?
Yes
No
Use this space to alert the court to any special case characteristics that may warrant individual management or accelerated disposition
Do you or your client need any disability accommodations?
If yes, please identify the requested accommodation:
Yes
No
Will an interpreter be needed?
If yes, for what language?
Yes
No
I certify that confidential personal identifiers have been redacted from documents now submitted to the court and will be
redacted from all documents submitted in the future in accordance with Rule 1:38-7(b).
Attorney Signature:
Revised Form Promulgated by 12/23/2020 Notice to the Bar, CN 10517 (Appendix XII-B1)
page 1 of 2
Save
Print
Clear
For Use by Clerk’s Office Only
Civil Case Information Statement
Payment type:
ck
cg
ca
(CIS)
Chg/Ck Number:
Use for initial Law Division
Amount:
Civil Part pleadings (not motions) under Rule 4:5-1
Pleading will be rejected for filing, under Rule 1:5-6(c),
Overpayment:
if information above the black bar is not completed
Batch Number:
or attorney’s signature is not affixed
Attorney/Pro Se Name
Telephone Number
County of Venue
Firm Name (if applicable)
Docket Number (when available)
Office Address
Document Type
Jury Demand
Yes
No
Name of Party (e.g., John Doe, Plaintiff)
Caption
Case Type Number
Are sexual abuse claims
Is this a professional malpractice case?
Yes
No
(See reverse side for listing)
alleged?
If you have checked “Yes,” see N.J.S.A. 2A:53A-27 and applicable case law
Yes
No
regarding your obligation to file an affidavit of merit.
Related Cases Pending?
If “Yes,” list docket numbers
Yes
No
Do you anticipate adding any parties
Name of defendant’s primary insurance company (if known)
(arising out of same transaction or occurrence)?
None
Yes
No
Unknown
The Information Provided on This Form Cannot be Introduced into Evidence.
Case Characteristics for Purposes of Determining if Case is Appropriate for Mediation
Do parties have a current, past or recurrent relationship?
If “Yes,” is that relationship:
Employer/Employee
Friend/Neighbor
Other (explain)
Yes
No
Familial
Business
Does the statute governing this case provide for payment of fees by the losing party?
Yes
No
Use this space to alert the court to any special case characteristics that may warrant individual management or accelerated disposition
Do you or your client need any disability accommodations?
If yes, please identify the requested accommodation:
Yes
No
Will an interpreter be needed?
If yes, for what language?
Yes
No
I certify that confidential personal identifiers have been redacted from documents now submitted to the court and will be
redacted from all documents submitted in the future in accordance with Rule 1:38-7(b).
Attorney Signature:
Revised Form Promulgated by 12/23/2020 Notice to the Bar, CN 10517 (Appendix XII-B1)
page 1 of 2
Side 2
Civil Case Information Statement
(CIS)
Use for initial pleadings (not motions) under Rule 4:5-1
CASE TYPES
(Choose one and enter number of case type in appropriate space on the reverse side.)
Track I - 150 days discovery
151
Name Change
506
PIP Coverage
175
Forfeiture
510
UM or UIM Claim (coverage issues only)
302
Tenancy
511
Action on Negotiable Instrument
399
Real Property (other than Tenancy, Contract, Condemnation, Complex
512
Lemon Law
Commercial or Construction)
801
Summary Action
502
Book Account (debt collection matters only)
802
Open Public Records Act (summary action)
505
Other Insurance Claim (including declaratory judgment actions)
999
Other (briefly describe nature of action)
Track II - 300 days discovery
305
Construction
603Y Auto Negligence – Personal Injury (verbal threshold)
509
Employment (other than Conscientious Employees Protection Act (CEPA)
605
Personal Injury
or Law Against Discrimination (LAD))
610
Auto Negligence – Property Damage
599
Contract/Commercial Transaction
621
UM or UIM Claim (includes bodily injury)
603N Auto Negligence – Personal Injury (non-verbal threshold)
699
Tort – Other
Track III - 450 days discovery
005
Civil Rights
608
Toxic Tort
301
Condemnation
609
Defamation
602
Assault and Battery
616
Whistleblower / Conscientious Employee Protection Act
604
Medical Malpractice
(CEPA) Cases
606
Product Liability
617
Inverse Condemnation
607
Professional Malpractice
618
Law Against Discrimination (LAD) Cases
Track IV - Active Case Management by Individual Judge / 450 days discovery
156
Environmental/Environmental Coverage Litigation
514
Insurance Fraud
303
Mt. Laurel
620
False Claims Act
508
Complex Commercial
701
Actions in Lieu of Prerogative Writs
513
Complex Construction
Multicounty Litigation (Track IV)
271
Accutane/Isotretinoin
601
Asbestos
274
Risperdal/Seroquel/Zyprexa
623
Propecia
281
Bristol-Myers Squibb Environmental
624
Stryker LFIT CoCr V40 Femoral Heads
282
Fosamax
625
Firefighter Hearing Loss Litigation
285
Stryker Trident Hip Implants
626
Abilify
286
Levaquin
627
Physiomesh Flexible Composite Mesh
289
Reglan
628
Taxotere/Docetaxel
291
Pelvic Mesh/Gynecare
629
Zostavax
292
Pelvic Mesh/Bard
630
Proceed Mesh/Patch
293
DePuy ASR Hip Implant Litigation
631
Proton-Pump Inhibitors
295
AlloDerm Regenerative Tissue Matrix
632
HealthPlus Surgery Center
296
Stryker Rejuvenate/ABG II Modular Hip Stem Components
633
Prolene Hernia System Mesh
297
Mirena Contraceptive Device
634
Allergan Biocell Textured Breast Implants
299
Olmesartan Medoxomil Medications/Benicar
300
Talc-Based Body Powders
If you believe this case requires a track other than that provided above, please indicate the reason on Side 1,
in the space under "Case Characteristics.
Please check off each applicable category
Putative Class Action
Title 59
Consumer Fraud
Revised Form Promulgated by 12/23/2020 Notice to the Bar, CN 10517 (Appendix XII-B1)
page 2 of 2
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