Preview
FILED: SUFFOLK COUNTY CLERK 10/11/2022 10:48 AM INDEX NO. 202495/2022
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 10/11/2022
(,,,uCS O
REQUEST FOR JUDICIAL INTERVENTION
SUPREME COURT, COUNTY OF SUFFOLK
Index No.: Date Index Issued: I /- FOr C urt Use O ly:
CAPTION: Enterthe completecase caption. If more
Do not use et al or et ano. space is needed,attacha caption
ridersheet. IAS EntryDate
In the Matter of the Application of
SALLY ANNE POLI Judge Assigned
For Leave to Assume the Name
SALLY ANNE FEE
Petitioner RJi Filed
Date
NATURE OF ACTION OR PROCEEDING Check only one box ar d specifywhere indicated
COMMERCIAL MATRIMONIAL
O Business Entity(includingcorporations,partnerships,LLCs, etc.) O Contested
O Contract NOTE: If there under
are children the ageof 18, completeand attach
the
MATRIMONIAL RJI Addendum (UCS-840M)
O Insurance (where insureris a party,
except arbitration)
For UncontestedMatrimonial use Uncontested
actions, DivorceRJI (UD-13)
O UCC sales,
(including negotiable instruments)
O Other Commercial (specify): TORTS
NOTE: For Commercial O Asbestos
Division
assignment requests22 NYCRR §
202.70(d),completeand attachthe COMMERCIAL DIV RJiAddendum O Child VictimsAct
(UCS-840C)..
O Environmental (specify):
REAL PROPERTY The applicationincludes O Medical, Dental,or PodiatricMalpractice
properties. O Motor Vehicle
O Condemnation O Products (specify):
Liability
O Mortgage Foreclosure(specify): O Residential O Commercial O Other Negligence (specify):
PropertyAddress: O Other Professional Malpractice(specify):
NOTE: For Foreclosure
actions a one-to
involving owner-
four-family, O Other Tort (specify):
occupied,residential or an owner-occupied
property, condominium,
complete and attachtheFORECLOSURE RJI Addendum (UCS-840F). SPECIAL PROCEEDINGS
O Tax Certiorari O CPLR Article
75 [see NOTE under
(Arbitration) Commercial]
O Tax Foreclosure O GPLR Article
78 or Officer)
(Body
O Other Real Property (specify): O Election Law
OTHER MATTERS O Extreme Risk Protection
Order
O Certificate
of O MHL Article9.60 (Kendra's Law)
Incorporation/Dissolution[see NOTE under
Commercial] O MHL Article10 (Sex Offender Confinement-Initial)
O Emergency Medical Treatment O MHL Article10 (Sex Offender Confinement-Review)
O Habeas Corpus O MHL Article81 (Guardianship)
O Local Court Appeal O Other Mental Hygiene (specify):
O Mechanic's Lien O Other Special Proceeding (specify):
liii NameChange [No fee- N.Y.Ct.Rules, § 202.6(b)]
O PistolPermit Revocation Hearing
O Sale or FinanceofReligious/Not-for-Profit
Property
O Other (specify):
STATUS OF ACTION OR PROCEEDING Answer YES or NO for es ary question
and enteradditional
information
where indicated
YES NO
Has a summons and complaintor summons with noticebeen filed? O O If yes,
date filed: / /
Has a summons and complaintor summons with noticebeen served? O O If yes,
date served: / /
Is this
action/proceedingbeing post-judgment?
filed O O If yes,
judgment date: / /
1 of 2
FILED: SUFFOLK COUNTY CLERK 10/11/2022 10:48 AM INDEX NO. 202495/2022
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 10/11/2022
NATURE OF JUDICIAL INTERVENTION Check one box only andenteradditional
information
where indicated.
O Compromise
Infants
O Extreme RiskProtectionOrder Application
O Note and/or
of issue of Readiness
Certificate
O Noticeof Medical,
Dental,or Podiatric
Malpractice Date issueJoined: / /
O Noticeof Motion Relief
Sought: Return Date: / /
O Noticeof Petition ReliefSought: Return Date: / /
O Orderto Show Cause ReliefSought: Return Date: / /
O OtherEx Parte Application ReliefSought:
O Poor Person Application
O Request for Preliminary
Conference
O Residential
Mortgage ForeclosureSettlement Conference
O Writ of HabeasCorpus
O Other(specify):
RELATED CASES: related
List any actions.For Matrimonial include
actions, criminal
any related and/orFamilyCourt cases.If none,leave
blank.
If additional
space complete
is required, and attachtheRJi Addendum (UCS-840A).
Case Title Index/Case Court Judge (If Relationship to Instant Case
No. assigned)
"Un-Rep"
PARTIES: For parties
withoutan attorney,
check box and enter
partyaddress, phone number and e-mailin the space
provided.
If additional
space is required,
comr leteand attachthe RJiAddendum (UCS-840A).
Parties Attorneys and/or Unrepresented Litigants Issue Joined Insurance
List parties in same order as listed in the
For represented name, firm name,
parties, provide attorney's For each defendant, Carriers
caption and Indicate roles (e.g. plaintiff,
address, indicate if issue has been
phone and e-mail . For unrepresented parties, provide For each
Un-Rep defendant; plaintiff, etc.). party's address, phone and e-mail. joined defendant,
3Cparty
indicate insurance
carrier, if
applicable
Name: 5 Plaza Drive
Sally Anne Poli NY 11787
Smithtown,
Phone: 516-840-8688 ¡ YES ¡ NO
Role(s):
Email: saraf3272@gmail.com
Petitioner
Name:
Role(s): O YES O NO
Name:
Role(s): ¡ YES ¡ NO
Name:
O Role(s) ¡ YES ¡ NO
I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INF ATI N AND BELIEF, THER ARE NO OTHER
RELATED ACTIONS OR PROCEEDINGS, EXCEPT AS NOTE ABOVE NOR H A ,EQUEST FOR JUDICIAL
INTERVENTION BEEN PREVIOUSLY BEEN FIL IN THI ACTIO OR OCEE NG.
Dated: /0 / / Ú-C 4./
SAL ANNE
n/a -unrepresented
ATTORNEY REGISTRATION NUMBER
2 of 2
Preview
FILED: SUFFOLK COUNTY CLERK 10/11/2022 10:48 AM INDEX NO. 202495/2022 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 10/11/2022 (,,,uCS O REQUEST FOR JUDICIAL INTERVENTION SUPREME COURT, COUNTY OF SUFFOLK Index No.: Date Index Issued: I /- FOr C urt Use O ly: CAPTION: Enterthe completecase caption. If more Do not use et al or et ano. space is needed,attacha caption ridersheet. IAS EntryDate In the Matter of the Application of SALLY ANNE POLI Judge Assigned For Leave to Assume the Name SALLY ANNE FEE Petitioner RJi Filed Date NATURE OF ACTION OR PROCEEDING Check only one box ar d specifywhere indicated COMMERCIAL MATRIMONIAL O Business Entity(includingcorporations,partnerships,LLCs, etc.) O Contested O Contract NOTE: If there under are children the ageof 18, completeand attach the MATRIMONIAL RJI Addendum (UCS-840M) O Insurance (where insureris a party, except arbitration) For UncontestedMatrimonial use Uncontested actions, DivorceRJI (UD-13) O UCC sales, (including negotiable instruments) O Other Commercial (specify): TORTS NOTE: For Commercial O Asbestos Division assignment requests22 NYCRR § 202.70(d),completeand attachthe COMMERCIAL DIV RJiAddendum O Child VictimsAct (UCS-840C).. O Environmental (specify): REAL PROPERTY The applicationincludes O Medical, Dental,or PodiatricMalpractice properties. O Motor Vehicle O Condemnation O Products (specify): Liability O Mortgage Foreclosure(specify): O Residential O Commercial O Other Negligence (specify): PropertyAddress: O Other Professional Malpractice(specify): NOTE: For Foreclosure actions a one-to involving owner- four-family, O Other Tort (specify): occupied,residential or an owner-occupied property, condominium, complete and attachtheFORECLOSURE RJI Addendum (UCS-840F). SPECIAL PROCEEDINGS O Tax Certiorari O CPLR Article 75 [see NOTE under (Arbitration) Commercial] O Tax Foreclosure O GPLR Article 78 or Officer) (Body O Other Real Property (specify): O Election Law OTHER MATTERS O Extreme Risk Protection Order O Certificate of O MHL Article9.60 (Kendra's Law) Incorporation/Dissolution[see NOTE under Commercial] O MHL Article10 (Sex Offender Confinement-Initial) O Emergency Medical Treatment O MHL Article10 (Sex Offender Confinement-Review) O Habeas Corpus O MHL Article81 (Guardianship) O Local Court Appeal O Other Mental Hygiene (specify): O Mechanic's Lien O Other Special Proceeding (specify): liii NameChange [No fee- N.Y.Ct.Rules, § 202.6(b)] O PistolPermit Revocation Hearing O Sale or FinanceofReligious/Not-for-Profit Property O Other (specify): STATUS OF ACTION OR PROCEEDING Answer YES or NO for es ary question and enteradditional information where indicated YES NO Has a summons and complaintor summons with noticebeen filed? O O If yes, date filed: / / Has a summons and complaintor summons with noticebeen served? O O If yes, date served: / / Is this action/proceedingbeing post-judgment? filed O O If yes, judgment date: / / 1 of 2 FILED: SUFFOLK COUNTY CLERK 10/11/2022 10:48 AM INDEX NO. 202495/2022 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 10/11/2022 NATURE OF JUDICIAL INTERVENTION Check one box only andenteradditional information where indicated. O Compromise Infants O Extreme RiskProtectionOrder Application O Note and/or of issue of Readiness Certificate O Noticeof Medical, Dental,or Podiatric Malpractice Date issueJoined: / / O Noticeof Motion Relief Sought: Return Date: / / O Noticeof Petition ReliefSought: Return Date: / / O Orderto Show Cause ReliefSought: Return Date: / / O OtherEx Parte Application ReliefSought: O Poor Person Application O Request for Preliminary Conference O Residential Mortgage ForeclosureSettlement Conference O Writ of HabeasCorpus O Other(specify): RELATED CASES: related List any actions.For Matrimonial include actions, criminal any related and/orFamilyCourt cases.If none,leave blank. If additional space complete is required, and attachtheRJi Addendum (UCS-840A). Case Title Index/Case Court Judge (If Relationship to Instant Case No. assigned) "Un-Rep" PARTIES: For parties withoutan attorney, check box and enter partyaddress, phone number and e-mailin the space provided. If additional space is required, comr leteand attachthe RJiAddendum (UCS-840A). Parties Attorneys and/or Unrepresented Litigants Issue Joined Insurance List parties in same order as listed in the For represented name, firm name, parties, provide attorney's For each defendant, Carriers caption and Indicate roles (e.g. plaintiff, address, indicate if issue has been phone and e-mail . For unrepresented parties, provide For each Un-Rep defendant; plaintiff, etc.). party's address, phone and e-mail. joined defendant, 3Cparty indicate insurance carrier, if applicable Name: 5 Plaza Drive Sally Anne Poli NY 11787 Smithtown, Phone: 516-840-8688 ¡ YES ¡ NO Role(s): Email: saraf3272@gmail.com Petitioner Name: Role(s): O YES O NO Name: Role(s): ¡ YES ¡ NO Name: O Role(s) ¡ YES ¡ NO I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INF ATI N AND BELIEF, THER ARE NO OTHER RELATED ACTIONS OR PROCEEDINGS, EXCEPT AS NOTE ABOVE NOR H A ,EQUEST FOR JUDICIAL INTERVENTION BEEN PREVIOUSLY BEEN FIL IN THI ACTIO OR OCEE NG. Dated: /0 / / Ú-C 4./ SAL ANNE n/a -unrepresented ATTORNEY REGISTRATION NUMBER 2 of 2