Preview
FILED: YATES COUNTY CLERK 09/16/2021 03:31 PM INDEX NO. 2021-5237
NYSCEF DOC. NO. 8 RECEIVED NYSCEF: 09/16/2021
UCS-840
REQUEST FOR JUDICIAL INTERVENTION (rev. 07/29/2019)
Yates Supreme COURT, COUNTY OF Yates
Index No: Date Index Issued: For Court Use Only:
CAPTION Enter the complete case caption. Do not use et al or et ano. If more space is needed, attach a caption rider sheet.
IAS Entry Date
In the matter of DRB Capital, LLC
Judge Assigned
Plaintiff(s)/Petitioner(s)
-against-
B. Buckle, Brighthouse Life Insurance Company
RJI Filed Date
Defendant(s)/Respondent(s)
NATURE OF ACTION OR PROCEEDING: Check only one box and specify where indicated.
COMMERCIAL MATRIMONIAL
☐ ☐
Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.)
Contested
NOTE: If there are children under the age of 18, complete and attach the
☐ Contract MATRIMONIAL RJI Addendum (UCS-840M).
☐ Insurance (where insurance company is a party, except arbitration)
For Uncontested Matrimonial actions, use the Uncontested Divorce RJI (UD-13).
☐ UCC (includes sales and negotiable instruments)
☐ Other Commercial (specify):
TORTS
NOTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202.70(d),
complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C). ☐ Asbestos
REAL PROPERTY: Specify how many properties the application includes:
☐ Child Victims Act
☐ Environmental (specify):
☐ Condemnation ☐ Medical, Dental, or Podiatric Malpractice
☐ ☐
Mortgage Foreclosure (specify):
Residential ☐ Commercial ☐ Motor Vehicle
Property Address: ☐ Products Liability (specify):
☐ Other Negligence (specify):
NOTE: For Mortgage Foreclosure actions involving a one to four-family, owner-
☐ Other Professional Malpractice (specify):
occupied residential property or owner-occupied condominium, complete and
attach the FORECLOSURE RJI ADDENDUM (UCS-840F).
☐ Other Tort (specify):
☐ Tax Certiorari - Section: Block: Lot:
SPECIAL PROCEEDINGS
☐ Tax Foreclosure
☐ Other Real Property (specify): ☐ CPLR Article 75 (Arbitration)
[see NOTE in COMMERCIAL section]
OTHER MATTERS
☐ CPLR Article 78 (Body or Officer)
☐ Election Law
☐ Certificate of Incorporation/Dissolution
[see NOTE in COMMERCIAL section]
☐ Extreme Risk Protection Order
☐ Emergency Medical Treatment
☐ MHL Article 9.60 (Kendra's Law)
☐ Habeas Corpus
☐ MHL Article 10 (Sex Offender Confinement-Initial)
☐ Local Court Appeal
☐ MHL Article 10 (Sex Offender Confinement-Review)
☐ Mechanic's Lien
☐ MHL Article 81 (Guardianship)
☐ Name Change
☐ Other Mental Hygiene (specify):
☐ Pistol Permit Revocation Hearing
☒ Other Special Proceeding (specify):
Transfer of Structure
☐ Sale or Finance of Religious/Not-for-Profit Property
☐ Other (specify):
STATUS OF ACTION OR PROCEEDING: Answer YES or NO for every question and enter additional information where indicated.
YES NO
Has a summons and complaint or summons with notice been filed? ☐ ☒ If yes, date filed:
Has a summons and complaint or summons with notice been served?☐ ☒ If yes, date served:
Is this action/proceeding being filed post-judgment? ☐ ☒ If yes, judgment date:
NATURE OF JUDICIAL INTERVENTION: Check one box only and enter additional information where indicated.
☐ Infant's Compromise
☐ Extreme Risk Protection Order Application
☐ Note of Issue/Certificate of Readiness
Date Issue Joined:
☐ Notice of Medical, Dental, or Podiatric Malpractice
Relief Requested: Return Date:
☐ Notice of Motion
Relief Requested: Return Date:
☐ Notice of Petition
Structured Settlement - Transfer
Relief Requested: Return Date:
☒ Order to Show Cause
Relief Requested:
☐ Other Ex Parte Application
☐ Poor Person Application
☐ Request for Preliminary Conference
☐ Residential Mortgage Foreclosure Settlement Conference
☐ Writ of Habeas Corpus
☐ Other (specify):
1 of 2
FILED: YATES COUNTY CLERK 09/16/2021 03:31 PM INDEX NO. 2021-5237
NYSCEF DOC. NO. 8 RECEIVED NYSCEF: 09/16/2021
RELATED CASES: List any related actions. For Matrimonial cases, list any related criminal or Family Court cases. If none, leave blank. If additional space
is required, complete and attach the RJI Addendum (UCS-840A).
Case Title Index/Case Number Court Judge (if assigned) Relationship to instant case
PARTIES: For parties without an attorney, check the "Un-Rep" box and enter the party's address, phone number and email in the space
provided. If additional space is required, complete and attach the RJI Addendum (UCS-840A).
Parties Attorneys and/or Unrepresented Litigants Issue Joined Insurance
Un-
Rep List parties in same order as listed in the
For represented parties, provide attorney's name, firm name, address, phone
For each defendant,
For each defendant,
caption and indicate roles (e.g., plaintiff,
and email. For unrepresented parties, provide party's address, phone and
indicate if issue has
indicate insurance
defendant; 3rd party plaintiff, etc.)email. been joined. carrier, if applicable.
Name: In the matter of DRB Donald Jensen, Jensen & Jensen, 125 Beverly Drive ,
☐ Capital, LLC Clarks Summit, PA 18411, 570-344-8723, ☐ YES ☒ NO
Role(s): Plaintiff/Petitioner jensenandjensen@aol.com
Name: Buckle, B. 4571 Harvey Road, Rushville, NY 14544
☒ ☐ YES ☒ NO
Role(s): Defendant/Respondent
Name: Brighthouse Life Insurance 2025 Leestown Road, Suite J, Lexington, KY 40511
☒ Company
☐ YES ☒ NO
Role(s): Defendant/Respondent
Name:
☐ ☐ YES ☐ NO
Role(s):
Name:
☐ ☐ YES ☐ NO
Role(s):
Name:
☐ ☐ YES ☐ NO
Role(s):
Name:
☐ ☐ YES ☐ NO
Role(s):
Name:
☐ ☐ YES ☐ NO
Role(s):
Name:
☐ ☐ YES ☐ NO
Role(s):
Name:
☐ ☐ YES ☐ NO
Role(s):
I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INFORMATION AND BELIEF, THERE ARE NO OTHER RELATED ACTIONS OR
PROCEEDINGS, EXCEPT AS NOTED ABOVE, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION BEEN PREVIOUSLY FILED IN THIS
ACTION OR PROCEEDING.
Dated: 09/16/2021 Donald W Jensen
Signature
2050185 Donald W Jensen
Attorney Registration Number Print Name
This form was generated by NYSCEF
2 of 2
Preview
FILED: YATES COUNTY CLERK 09/16/2021 03:31 PM INDEX NO. 2021-5237 NYSCEF DOC. NO. 8 RECEIVED NYSCEF: 09/16/2021 UCS-840 REQUEST FOR JUDICIAL INTERVENTION (rev. 07/29/2019) Yates Supreme COURT, COUNTY OF Yates Index No: Date Index Issued: For Court Use Only: CAPTION Enter the complete case caption. Do not use et al or et ano. If more space is needed, attach a caption rider sheet. IAS Entry Date In the matter of DRB Capital, LLC Judge Assigned Plaintiff(s)/Petitioner(s) -against- B. Buckle, Brighthouse Life Insurance Company RJI Filed Date Defendant(s)/Respondent(s) NATURE OF ACTION OR PROCEEDING: Check only one box and specify where indicated. COMMERCIAL MATRIMONIAL ☐ ☐ Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.) Contested NOTE: If there are children under the age of 18, complete and attach the ☐ Contract MATRIMONIAL RJI Addendum (UCS-840M). ☐ Insurance (where insurance company is a party, except arbitration) For Uncontested Matrimonial actions, use the Uncontested Divorce RJI (UD-13). ☐ UCC (includes sales and negotiable instruments) ☐ Other Commercial (specify): TORTS NOTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202.70(d), complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C). ☐ Asbestos REAL PROPERTY: Specify how many properties the application includes: ☐ Child Victims Act ☐ Environmental (specify): ☐ Condemnation ☐ Medical, Dental, or Podiatric Malpractice ☐ ☐ Mortgage Foreclosure (specify): Residential ☐ Commercial ☐ Motor Vehicle Property Address: ☐ Products Liability (specify): ☐ Other Negligence (specify): NOTE: For Mortgage Foreclosure actions involving a one to four-family, owner- ☐ Other Professional Malpractice (specify): occupied residential property or owner-occupied condominium, complete and attach the FORECLOSURE RJI ADDENDUM (UCS-840F). ☐ Other Tort (specify): ☐ Tax Certiorari - Section: Block: Lot: SPECIAL PROCEEDINGS ☐ Tax Foreclosure ☐ Other Real Property (specify): ☐ CPLR Article 75 (Arbitration) [see NOTE in COMMERCIAL section] OTHER MATTERS ☐ CPLR Article 78 (Body or Officer) ☐ Election Law ☐ Certificate of Incorporation/Dissolution [see NOTE in COMMERCIAL section] ☐ Extreme Risk Protection Order ☐ Emergency Medical Treatment ☐ MHL Article 9.60 (Kendra's Law) ☐ Habeas Corpus ☐ MHL Article 10 (Sex Offender Confinement-Initial) ☐ Local Court Appeal ☐ MHL Article 10 (Sex Offender Confinement-Review) ☐ Mechanic's Lien ☐ MHL Article 81 (Guardianship) ☐ Name Change ☐ Other Mental Hygiene (specify): ☐ Pistol Permit Revocation Hearing ☒ Other Special Proceeding (specify): Transfer of Structure ☐ Sale or Finance of Religious/Not-for-Profit Property ☐ Other (specify): STATUS OF ACTION OR PROCEEDING: Answer YES or NO for every question and enter additional information where indicated. YES NO Has a summons and complaint or summons with notice been filed? ☐ ☒ If yes, date filed: Has a summons and complaint or summons with notice been served?☐ ☒ If yes, date served: Is this action/proceeding being filed post-judgment? ☐ ☒ If yes, judgment date: NATURE OF JUDICIAL INTERVENTION: Check one box only and enter additional information where indicated. ☐ Infant's Compromise ☐ Extreme Risk Protection Order Application ☐ Note of Issue/Certificate of Readiness Date Issue Joined: ☐ Notice of Medical, Dental, or Podiatric Malpractice Relief Requested: Return Date: ☐ Notice of Motion Relief Requested: Return Date: ☐ Notice of Petition Structured Settlement - Transfer Relief Requested: Return Date: ☒ Order to Show Cause Relief Requested: ☐ Other Ex Parte Application ☐ Poor Person Application ☐ Request for Preliminary Conference ☐ Residential Mortgage Foreclosure Settlement Conference ☐ Writ of Habeas Corpus ☐ Other (specify): 1 of 2 FILED: YATES COUNTY CLERK 09/16/2021 03:31 PM INDEX NO. 2021-5237 NYSCEF DOC. NO. 8 RECEIVED NYSCEF: 09/16/2021 RELATED CASES: List any related actions. For Matrimonial cases, list any related criminal or Family Court cases. If none, leave blank. If additional space is required, complete and attach the RJI Addendum (UCS-840A). Case Title Index/Case Number Court Judge (if assigned) Relationship to instant case PARTIES: For parties without an attorney, check the "Un-Rep" box and enter the party's address, phone number and email in the space provided. If additional space is required, complete and attach the RJI Addendum (UCS-840A). Parties Attorneys and/or Unrepresented Litigants Issue Joined Insurance Un- Rep List parties in same order as listed in the For represented parties, provide attorney's name, firm name, address, phone For each defendant, For each defendant, caption and indicate roles (e.g., plaintiff, and email. For unrepresented parties, provide party's address, phone and indicate if issue has indicate insurance defendant; 3rd party plaintiff, etc.)email. been joined. carrier, if applicable. Name: In the matter of DRB Donald Jensen, Jensen & Jensen, 125 Beverly Drive , ☐ Capital, LLC Clarks Summit, PA 18411, 570-344-8723, ☐ YES ☒ NO Role(s): Plaintiff/Petitioner jensenandjensen@aol.com Name: Buckle, B. 4571 Harvey Road, Rushville, NY 14544 ☒ ☐ YES ☒ NO Role(s): Defendant/Respondent Name: Brighthouse Life Insurance 2025 Leestown Road, Suite J, Lexington, KY 40511 ☒ Company ☐ YES ☒ NO Role(s): Defendant/Respondent Name: ☐ ☐ YES ☐ NO Role(s): Name: ☐ ☐ YES ☐ NO Role(s): Name: ☐ ☐ YES ☐ NO Role(s): Name: ☐ ☐ YES ☐ NO Role(s): Name: ☐ ☐ YES ☐ NO Role(s): Name: ☐ ☐ YES ☐ NO Role(s): Name: ☐ ☐ YES ☐ NO Role(s): I AFFIRM UNDER THE PENALTY OF PERJURY THAT, UPON INFORMATION AND BELIEF, THERE ARE NO OTHER RELATED ACTIONS OR PROCEEDINGS, EXCEPT AS NOTED ABOVE, NOR HAS A REQUEST FOR JUDICIAL INTERVENTION BEEN PREVIOUSLY FILED IN THIS ACTION OR PROCEEDING. Dated: 09/16/2021 Donald W Jensen Signature 2050185 Donald W Jensen Attorney Registration Number Print Name This form was generated by NYSCEF 2 of 2