P.O. Box 32040 | Newark, NJ 07102 - Volunteer Lawyers for Justice

P.O. Box 32040 | Newark, NJ 07102 | Telephone (973) 645-1955 | Fax (973) 645-1954

IMPORTANT NOTICE

These forms are part of Volunteer Lawyers for Justice’s free Divorce Clinic. If you got the forms outside of the clinic, you can call to see if you qualify for service at (973) 645-1955. These forms and instructions are provided to help self-represented people in New Jersey to be able to file for or respond to a divorce. These packets are NOT intended to provide you with complete information about all of your rights or responsibilities in your case.

You are representing yourself in your case. You are solely responsible for meeting all timelines in your case. If you have questions about your divorce, you should contact an attorney. The Essex County Bar Association Lawyers Referral Service has attorneys who will charge a reduced consultation fee. Their phone number is (973)622-6204.

The Essex County Dissolution Unit’s office is located in the Wilentz Justice Complex, 212 Washington Street, Room 1207, Newark NJ 07102.

Should you need to contact the Dissolution Unit for any questions regarding your case, their new General Information phone number is 973-776-9300 ext. 57040.

More information can also be found online at https://www.njcourts.gov/selfhelp/selfhelp_divorce.html


SELF-HELP DIVORCE INSTRUCTIONS

General Instructions

Thank you for your interest in Volunteer Lawyers for Justice’s (VLJ) self-help divorce clinic. You are responsible for handling your own case; you will not have an attorney representing you in this matter. In the attached packet you will find instructions and forms for filing a responsive pleading in a divorce case.

• Read carefully through the instructions in this packet before you start filling out any forms.

• It is your responsibility to complete this packet. The volunteers at the clinic will not fill out thispacket for you.

• PLEASE PRINT NEATLY ON ALL DOCUMENTS TO AVOID HAVING YOUR COMPLAINT RETURNED BYTHE COURT CLERK’S OFFICE.

• Court forms are repetitive. Try not to become frustrated with how often you need to write outyour name and address.

• A responsive pleading means that you are filing a response to the divorce complaint. You can filean Answer or an Answer and Counterclaim.

• “Pro se” means that you are representing yourself in your case.

• The person filing a response in the case is the “Defendant” and the other spouse is the “Plaintiff.”

(Your Spouse’s First and Last Name)

(Your First and Last Name)

John Doe,

Plaintiff

vs.

Jane Doe,

SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION: FAMILY PART ESSEX COUNTY

DOCKET NO. FM – 07 -1234-19

CIVIL ACTION

Defendant ANSWER or ANSWER AND COUNTERCLAIM

• Our volunteers are here to help you. You should start filling out the forms the best you can. If you have questions, raise your hand and a volunteer or VLJ staff member will come to assist you.

• As a reminder, these are the forms that you will need to get your case started. These forms alone will not finalize your divorce. Depending upon the issues in your divorce, your case will follow two very different tracks----the settlement track or the trial track.

• This clinic is designed to have you come back after your case is scheduled for a case management conference so that we can assist you with the later steps of the divorce.

• If you have questions during the process, you can call VLJ at 973-645-1955.

(Check one)

• When looking at court forms you can locate the name of the document by looking to the top rightportion of the first page of each form. This heading is called the CAPTION. The name of the formin this sample caption on the next page is “Answer” or “Answer and Counterclaim.”

Jane Doe (NAME) 123 Essex Avenue, Apt. 123 (ADDRESS) Newark, NJ 12345 (CITY, STATE, ZIP) 973-973-555-1234 (PHONE) Pro Se Plaintiff

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SELF-HELP DIVORCE INSTRUCTIONS Part 4: Filing a Response to a Divorce Complaint

If you were served with a Summons and divorce Complaint you only have 35 calendar days to respond. Your written response must be filed with the court and served upon your spouse or spouse’s attorney.

This packet includes the following forms:

Step 1: Fill out the forms for your response

FORM 4A – Answer or Answer and Counterclaim FORM 4B – Certification and Verification of Non-Collusion FORM 4C – Certification of Service FORM 4D – Certification of Insurance FORM 4E– Rule 5:4-2(h) Certification by Self-Represented Litigant FORM 4F – Confidential Litigant Information Sheet FORM 4G – Filing Fee Waiver Request FORM 4H– Case Information Statement FORM 4I – Cover letter to the court clerk

• You will first need to decide if you should file an Answer or Answer and Counterclaim (Form4A). This form asks you to “admit” or “deny” the things your spouse wrote in each paragraphof the divorce complaint. If you agree with the paragraph (for example, “The plaintiff wasmarried to the defendant on December 1, 1997 in Newark, NJ) then check “admit.” If youdisagree, check “deny.” You should do this for each numbered paragraph in the divorcecomplaint.

• If you would like the court to make additional orders, for example, you would like alimony,custody of your children, or half of your spouse’s pension, you need to let the court and yourspouse know by filing a “counterclaim.” If you are asking the court to make additional orders,on page 2, check the box named “counterclaim for divorce.” You will need to give the courtfacts about your case and write out what else you want (support, property, custody orparenting time with your children.)

• After you fill out Form 4A, you should fill out Forms 4B-4F.

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Step 2: Filing fee or fee waiver

Step 3: File your documents with the court

Filing fee: • A filing fee of $175.00 is payable by cash, check, or money order payable to Treasurer,

State of New Jersey• If you have a minor child (under 18) with your spouse, there is an additional $25.00 fee for

a mandatory parenting class; your fees will be $200.00 in total.OR Fee waiver (FORM 4G): • You may qualify for a fee waiver if your income is below 150% of the federal poverty

level• Complete FORM 4G – Filing Fee Waiver Request• Attach a copy of:

o Two months of income. Proof of income includes: Social Security award letter Public assistance award letter W-2 Last 3 paystubs from employment or unemployment

o Six months of bank statements (all bank accounts)• Make ONE copy of completed FORM 4G and attachments

• Prepare a large (9”x12”) self-addressed stamped envelope• Make two copies of FORMS 4A-4F if you are filing an Answer OR Answer and Counterclaim• Enclose:

o The original and one copy of FORMS 4A-4Fo The cover letter to the court clerk FORM 4Jo Your filing fee (do not mail cash) OR the original and one copy of FORM 4Go The self-addressed stamped envelope with $1.75 postage.o Keep one copy for your records

• Form 4F is required to be filed with the court but you do NOT need to give a copy to your spouse. Please complete it fully.

• Mail your documents to (if filing in Essex County):

Superior Court of New Jersey – FinanceRoom 111, 1st FloorWilentz Justice Complex212 Washington StreetNewark, NJ 07102

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Step 4: Service

Step 5: Wait for the court to file your pleadings

Step 6: Case Information Statement

Step 7: Case Management Conference

• Wait for the clerk to return your copy of the divorce documents dated and marked “FILED”• You should receive your documents in 1-2 weeks• If you have not received your filed copy after 2 weeks, call the clerk’s office at 908-527-4787• The clerk may ask your name, date of birth, address, and/or social security number• The clerk will schedule your case for a case management conference before a judge

• Mail copies of FORMS 4A – 4E to your spouse (or spouse’s attorney) by regular and certifiedmail, return receipt requested. If you are not familiar with this type of mailing, ask the postalclerk at the post office what forms you will need to complete. You should note, certified mail,return receipt requested will add another $6.35 onto your postage

• You do not need to send your spouse a copy of Form 4F• Keep a copy of your return receipt

• Complete FORM 4H• Both parties are required to complete the Case Information Statement (CIS). The CIS can

take several hours to complete. You are required to attach certain documents to your CIS,including: your paystubs, W-2, last filed tax returns, prior court orders, certification ofinsurance, documentation about any assets, proof of bills or debts. See page 10 of the CISfor a complete list of the documents you are required to attach

• Your CIS is due to the clerk’s office within 20 days from the date your Answer is stampedfiled. However, you may file your completed CIS when you file your Answer.

• You must provide your spouse or his/her attorney with a copy of your CIS• Likewise, your spouse or his/her attorney must provide you with copies of his/her CIS

• Your case will be assigned to a judge for review• You and your spouse (or spouse’s attorney) will receive a notice from the judge’s

chambers about attending a case management conference• The notice will outline what documents you and your spouse (or spouse’s attorney) must

return to the court. The judge will request that both parties provide copies of their mostrecently filed CIS. These documents must be provided at least 10 days prior to the casemanagement conference

• The judge may require both parties to submit a position statement (written statement)about the outstanding issues in the case

• You must provide your spouse or his/her attorney with a copy of your position statementif you send one

• Likewise, your spouse or his/her attorney must provide you with copies of his/her positionstatement

• All parties are required to attend the case management conference

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Need additional help?

If you need help with the next part of your divorce case call VLJ at 973-645-1955 to find out the next clinic date.

As a reminder, you are representing yourself in this case and you are solely responsible for meeting all court deadlines.

FORM 4A

Page 1 of 5

(Your spouse’s first and last name)

(Your first and last name)

_____________________________ (NAME)

_____________________________ (ADDRESS)

_____________________________ (CITY, STATE, ZIP)

_____________________________ (PHONE)

Pro Se Defendant

_______________________,

Plaintiff

vs.

_______________________,

SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION: FAMILY PART _____________ COUNTY

DOCKET NO. FM – _________________

CIVIL ACTION

Defendant ANSWER or ANSWER AND COUNTERCLAIM

Defendant, ________________________________________, currently residing

at ____________________________________________________________, New

Jersey, by way of Answer to Plaintiff’s complaint says:

1. I Admit Deny (check one) the allegations contained in paragraph 1.







(Your address)

(Check one)

FORM 4A

Page 2 of 5

(Date of marriage)

(City and state where you were married)










WHEREFORE, Defendant demands judgment dismissing Plaintiff’s complaint.

COUNTERCLAIM FOR DIVORCE (IRRECONCIABLE DIFFERENCES)

1. The Defendant was lawfully married to Plaintiff on __________________,

in a (check one) civil or religious ceremony in ____________________ _____.

2. Defendant was a bona fide resident of the State of New Jersey when

this cause of action arose, and has ever since and for more than one year preceding the

commencement of this action continued to be such a bona fide resident.

3. The plaintiff resides at __________________________________________________

_____________________________________________________________________

4. Defendant resided at ___________________________________________________,

when this action arose.

(Your spouse’s address – include city and state)

(Your address – street, city and state)

Check the box listed above if you have a counterclaim.

FORM 4A

Page 3 of 5

5. Irreconcilable differences have arisen, which have caused the breakdown of the

marriage for a period of six (6) months, which make it appear that the marriage

should be dissolved and that there is no reasonable prospect of reconciliation.

6. Child(ren) (check one) were OR were not born or adopted with your spouse

Name of child Date of birth

Child is in the custody of:

Has the child lived in NJ for the past six (6) months? YES or NO

YES or NO

YES or NO

YES or NO

YES or NO

7. There have been no previous proceedings between the parties regarding the

marriage, maintenance, or its dissolution in any court except for (i.e. child support,

alimony, domestic violence, previous divorce filings, etc). Please list all docket

numbers and types of matters:____________________________________________

_____________________________________________________________________

_____________________________________________________________________

8. During the course of the marriage the parties (check one) did not acquire OR

did acquire property, real and/or personal, and/or debts, which are subject to

equitable distribution.

FORM 4A

Page 4 of 5

WHEREFORE, Defendant demands judgment (check all that apply):

Dissolving the marriage between the parties.

Awarding sole / joint legal custody of the minor child(ren) of the marriage to__________________________.

Awarding sole /joint physical custody of the minor child(ren) of the marriage to__________________________.

Granting parenting time of the minor child(ren) to _________________________.

Ordering the equitable distribution of all property and/or debts which were legally and

beneficially acquired by the parties during the course of the marriage.

Permitting ________________ to resume her maiden name of ______________________.

(Plaintiff or Defendant)



Compelling the _______________ to support the child(ren) of the marriage. In(Plaintiff or Defendant)

accordance with NJSA 2A:17-56.7a et seq., the child support provisions of a Court Order are

subject to income withholding on its effective date. The income withholding is effective

upon all types of income, including wages from current and future employment.

Continuing current award for child support pursuant to docket

number:___________________________________________________.

Directing _______________________ to provide medical insurance coverage for the(Plaintiff or Defendant)

child(ren).

Directing ______________________ to name the child(ren) as irrevocable beneficiary on(Plaintiff or Defendant)

any work related life insurance coverage that may be obtained, and name the plaintiff as

irrevocable trustee.

Directing ___________________ to contribute, according to his or her means, to any(Plaintiff or Defendant)

future educational costs of the child(ren).

Ordering ________________________ to pay alimony to __________________.(Plaintiff or Defendant) (Plaintiff or Defendant)


FORM 4A

Page 5 of 5

Other relief:

_________________________________________________________________

_________________________________________________________________

Other relief:

_________________________________________________________________

_________________________________________________________________

For such other relief as the Court deems equitable and just.

_______________________________________________ Defendant, Pro Se (Your signature)

________________________________________ Defendant, Pro Se (Print your name)

Date: ___________________________

FORM 4B

Certification of Verification and Non-Collusion

1. I am the Defendant in the foregoing Answer and Counterclaim. The allegations

contained in the Answer and Counterclaim are true to the best of my knowledge,

information and belief. The said Answer and Counterclaim is made in truth and good

faith and without collusion for the causes set forth therein.

2. The matter in controversy in the within action is not the subject of any other

action pending in any Court or pending arbitration proceeding, nor is any such court

action or arbitration proceeding presently contemplated.

3. There are no other persons who should be joined in this action at this time.

4. I certify that the foregoing statements made by me are true. I am aware that if

any of the foregoing statements made by me are willfully false, I am subject to

punishment.

Date: ________ __ (Defendant’s signature) Defendant Pro Se

FORM 4C

(Your name)

(Date)

(Plaintiff’s name)

CERTIFICATION OF SERVICE

I, ______________________________________, of full age, certify that a copy of the

foregoing Answer and/or Counterclaim, together with all supporting exhibits have been

forwarded to the Clerk of the Superior Court, Chancery Division, Family Part, Essex County,

Dissolution Unit, 212 Washington Street, Newark New Jersey, 07102 and served by regular

and certified mail on ___________________ upon the

Plaintiff, _______________________________________ at the following address:

____________________________________ (Plaintiff’s name)

____________________________________ (Address)

____________________________________ (Apartment/ Unit Number)

____________________________________ (City, State, Zip Code)

I certify that the foregoing was served in the manner and time prescribed by the Rules

of Court.

Date: ________ ________ (Defendant’s signature) Defendant Pro Se

FORM 4D

Page 1 of 2

(Your spouse’s first and last name)


_____________________________ (NAME)

_____________________________ (ADDRESS)

_____________________________ (CITY, STATE, ZIP)

_____________________________ (PHONE)

Pro Se Defendant

_______________________,

Plaintiff

vs.

_______________________, Defendant

SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION: FAMILY PART _______________ COUNTY

DOCKET NO. FM --_________________

CIVIL ACTION

CERTIFICATION OF INSURANCE PURSUANT TO R. 5:4-2(f)

I, ________________________________ being of full age, hereby certify: (Your name)

1. I am the defendant in the foregoing Answer and/or Counterclaim for Divorce. To thebest of my knowledge and belief, the insurance coverage within this Certificationrepresents all insurance coverage of myself, my spouse and our children in this matter.

2. To the best of my knowledge and belief, none of the insurance coverage listed withinthis Certification was canceled or modified within the ninety days before the date of thisCertification.

(Fill out all applicable sections. If not applicable, write in “not applicable”)

LIFE INSURANCE Name of Company: ___________________ Address: __________________________________ Policy Number: ______________________ Beneficiary: ________________________________ Face Amount: _______________________ Name of Insured: ___________________________ Policy Owner: _______________________ Policy Term (if applicable): ___________________

FORM 4D

Page 2 of 2

HEALTH INSURANCE Name of Insured:_________________________ Name of Company: ______________________ Address: ______________________________________________________________________ I.D. Number: ____________________________ Group Number: _________________________Coverage Type: Single Parent- Child Family Optical Hospital Diagnostic Drug Dental Major MedicalCheck if made available through employment personally obtained

AUTOMOBILE INSURANCE Name of Company: _____________________________________________________________ Address of Company: ___________________________________________________________ Policy Number: ________________________________________________________________ Policy Expiration Date: Make of Vehicle: _____________________ Model of Vehicle: Year of Vehicle: ______________________ Coverage Limits: _______________________________________________________________ Lawsuit Threshold Yes No Umbrella Coverage Yes No Umbrella Coverage: ___________________________________________________ Driver(s) of Vehicle: ___________________________________________________ Lien holder/Lessor (if applicable): ________________________________________ Address of Lien holder/Lessor: ___________________________________________ Use of Vehicle: Personal Business Personal and Business

HOMEOWNER’S OR RENTAL INSURANCE Name of Company: ______________________________________________________ Address of Company:_____________________________________________________ Policy Number: Policy Expiration Date: _______________ Address of Covered Residence: _____________________________________________ Coverage Limits: _________________________________________________________ Umbrella Coverage Yes No Umbrella Coverage: $_________________ Mortgagee (if applicable): __________________________________________________ Address of Mortgagee: ____________________________________________________ Rider(s) to Policy: Jewelry Furs Artwork Other _________________________

I certify that all of the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.

Dated: _____________ (Defendant’s signature) Defendant Pro Se

Appendix XXVII-B Certification of Notification of Complementary Dispute Resolution Alternatives

-- Certification by Self-Represented Litigant

_________________________________ Plaintiff,

v.

_________________________________ Defendant

SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION - FAMILY PART ___________________ COUNTY DOCKET NO. FM-___________________

CIVIL ACTION

RULE 5:4-2(h) CERTIFICATION BY SELF-REPRESENTED LITIGANT

__________________________, of full age, hereby certifies as follows:

1. I am the Plaintiff Defendant in the above captioned matter.

2. I make this Certification pursuant to New Jersey Court Rule 5:4-2(h).

3. I have read the document entitled “Divorce -- Dispute Resolution Alternatives to Conventional

Litigation”.

4. I thus have been informed as to the availability of complementary dispute resolution alternatives

to conventional litigation.

I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing

statements made by me are willfully false, I am subject to punishment.

_______________________________________ Dated:

Note: Adopted as Rules Appendix XXVII-B July 16, 2009 to be effective September 1, 2009. CN: 10889-English

FORM 4E

DIVORCE – DISPUTE RESOLUTION ALTERNATIVES TO CONVENTIONAL LITIGATION*

[Text Promulgated 12/04/06 as Approved by the Supreme Court]

Resolving issues concerning your divorce can be costly and difficult. While only a judge

can actually grant a divorce, division of your property and your debts, alimony, child support,

custody and parenting time are some of the other issues that may need to be resolved. A judge

can decide all issues at trial. However, there are other ways to resolve many of the issues in your

divorce. These alternate dispute resolution methods offer greater privacy than resolving the

issues in a public trial. They also may be faster and less expensive, and may reduce the level of

conflict between you and your spouse during your divorce. You are encouraged to discuss

alternative dispute resolution with your lawyer to decide whether these alternate methods may

help you and your spouse resolve as many of the issues relating to your divorce as possible

before the matter is presented to the judge.

What follows are short descriptions of various forms of alternative dispute resolution that

may be used in divorce cases.

MEDIATION**

Mediation is a means of resolving differences with the help of a trained, impartial third

party. The parties, with or without lawyers, are brought together by the mediator in a neutral

* This constitutes the “descriptive material” referenced in Rule 5:4-2(h) that each divorce litigantmust receive and certify as having received (using the attached certification forms).

** Note: The adoption of Rule 5:4-2(h) and the promulgation of this descriptive material is in no way intended to indicate any change in the Court’s policy, grounded in statutes and court rules, against mediation in any matter in which a temporary or final restraining order has been entered pursuant to the Prevention of Domestic Violence Act.

1

FORM 4E

setting. A mediator does not represent either side and does not offer legal advice. Parties are

encouraged to retain an attorney to advise them of their rights during the mediation process. The

mediator helps the parties identify the issues, gather the information they need to make informed

decisions, and communicate so that they can find a solution agreeable to both. Mediation is

designed to facilitate settlements in an informal, non-adversarial manner. The court maintains a

roster of approved mediators or you can use private mediation services. The judge would still

make the final determination as to whether to grant the divorce.

ARBITRATION

In an arbitration proceeding, an impartial third party decides issues in a case. The parties

select the arbitrator and agree on which issues the arbitrator will decide. The parties also agree in

advance whether the arbitrator’s decisions will be binding on them or instead treated merely as a

recommendation. While an arbitrator may decide issues within a divorce case, the judge would

still make the final determination as to whether to grant the divorce.

USE OF PROFESSIONALS

Parties in a divorce may also seek the assistance of other skilled professionals to help

resolve issues in a case, such as attorneys, accountants or other financial professionals, and

various types of mental health professionals (e.g., psychiatrists, psychologists, social workers,

therapists). These professionals may help the parties resolve all of the issues or just specific

portions of the case. As with mediation and arbitration, parties making use of these

professionals to resolve issues in the divorce are encouraged to consult their attorney for advice

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FORM 4E

throughout this process. While this approach may resolve some issues in the case, the judge

would still need to make the final decision to grant the divorce.

COMBINATIONS OF ALTERNATIVES

Depending on your circumstances, it may be helpful for you to use a combination of

mediation, arbitration, and skilled professionals to resolve issues in your divorce.

CONCLUSION

Just as every marriage is unique, every divorce is unique as well. The specific

circumstances of your divorce determine what method or methods of dispute resolution are best

suited to resolve issues in your divorce. You are encouraged to ask your attorney about these

alternative dispute resolution methods to resolve issues relating to your divorce.

Using these alternative dispute resolution methods allows you to participate in the

decision on those issues, rather than leaving all of the issues to the judge to decide. And

presenting the judge with a case in which the only decision remaining is whether to grant the

divorce will permit that decision to be made more expeditiously. While the judge must be the

one to decide whether to grant the divorce, your role in deciding some or all of the other issues

can be enhanced through these alternative dispute resolution methods.

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FORM 4E

Revised: 10/2012, CN 10486 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


Professional, Occupational, Recreational Licenses (include types and license numbers)

Professional, Occupational, Recreational Licenses (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


Children Information

Name (last, first, middle initial) Date of Birth Race Sex Social Security 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

FORM 4F

Revised: 03/26/2018, CN 11208 page 1 of 8

General- Fee Waiver How to File a Fee Waiver March 2018

How to File for a Fee Waiver - All Courts Who Should Use This Packet?

You should use this packet if you believe that you cannot afford to pay the filing fees in your case. This form may be used when applying for a fee waiver in the Supreme Court, Appellate Division, Superior Court and Tax Court. This request is based upon your financial need. It requires the submission of financial records/documents in order for a judge to determine if your filing fees should be waived. This request can be filed by any party prior to and at any point during the lawsuit, except where a party is requesting a waiver of filing fees for the Supreme Court and Superior Court, Appellate Division.

Please note that Rule 1:5-6 directs the clerk of the court to return papers as “received, but not filed,” when they are not accompanied by the required filing fee. For this reason, the filing fee or application to waive filing fee should accompany any filing that requires a fee. This packet explains how to file this request.

Legal Services of New Jersey and the associated regional programs, as well as public interest or legal services organizations, law school clinical or pro bono programs which have been certified by the Court pursuant to Rule 1:21-11 for fee waiver status are exempt from filing fees and are not required to make a request for a fee waiver.

Where the person filing these forms is requesting a waiver of fees in the Superior Court, Appellate Division, the application must first be made in the trial court pursuant to Rule 2:7-1. If the request is denied in the trial court, within 20 days, the person requesting the fee waiver may then apply for a fee waiver in the Appellate Division. If the person is requesting a waiver of fees in an appeal of an administrative agency determination, the application must be filed in the Appellate Division. For questions related to where the application should be filed, please contact the Superior Court Clerk’s Office at (609) 421-6100.

With limited exceptions, any paper filed with the court can be looked at by the public upon request. You may only file this request on behalf of yourself and not for anyone else. A Power of Attorney does not allow you to file on behalf of anyone else.

In the trial courts, if you are granted a fee waiver and are awarded more than $2,000 in that same matter, you will be responsible to repay any and all fees waived by the court, as determined by court order.

FORM 4G


Please follow the instructions included in this packet and make sure that all documents in support of this request are attached. You will be required to complete the following:

• Form A – Certification/Petition/Application in Support of Fee Waiver. Attach your financialrecords/documentation to the Certification/Petition/Application.

• Form B – Order Waiving Filing Fees

Your fee waiver application may not be granted if you do not include all required income documentation. The court may request additional income verification, including but not limited to, state and federal tax returns and other sources of income. Keep a copy of whatever you file with the Court for your own records.

Note: These materials have been prepared by the New Jersey Administrative Office of the Courts for use by self-represented litigants. The instructions and forms will be periodically updated as necessary to reflect current New Jersey statutes and court rules. The most recent version of the forms will be available on the Judiciary’s Internet site njcourts.gov. However, you are ultimately responsible for the content of your court papers.

Completed forms for the Supreme Court, Appellate Division and Tax Court are to be submitted to the respective Clerk’s Office.

Completed forms for the Superior Court are to be submitted to the courthouse in the county where you are going to file your case or where the case is already filed. A listing of the courthouses is available at njcourts.gov.

For questions related to where the application should be filed, please contact the Superior Court Clerk’s Office at (609) 421-6100.


The numbered steps below tell you what forms you will need to fill out and what to do with them. Each form should be typed or printed clearly on 8 ½” x 11” white paper only. Forms may not be filed on a different size or color paper.

Steps for Filing a Fee Waiver

STEP 1 Complete the Certification/Petition/Application in Support of a Fee Waiver (Form A). The Certification/Petition/Application in Support of a Fee Waiver tells the court the reasons why you want the fee waiver and the facts supporting why the court should grant your request. In the Certification/Petition/ Application you will make a disclosure of your financial and employment situation.

All fee waiver applications must be filed at the courthouse or appropriate Clerk's office where you are going to file your case or where the case is already filed. A complete list of courthouses can be found at the Judiciary’s website: njcourts.gov.

STEP 2 Complete the proposed form of Order (Form B) Fill in the information at the top of the page up to where you identify yourself as a plaintiff or defendant. Leave the line for the date of the Order and the rest of the form blank. The terms

of the Order will be completed by the judge when the application is decided.

STEP 3 Check Your Completed Forms and Make Copies Check your forms and make sure they are complete. Remove all instruction sheets. Make sure you have signed the forms where you are asked to sign them.

STEP 4 Mail or Deliver Form A (Certification/Petition/Application in Support of a Fee Waiver), Form B (Proposed Form of Order) and all documentation to the Court. You are required to provide a copy of Forms A and B to the court. Please black out all personal and confidential information, such as Social Security numbers, driver’s license numbers, vehicle plate numbers, insurance policy numbers, active financial account numbers or active credit card numbers.

A complete list of Clerk’s Offices and courthouses can be found at the Judiciary’s site njcourts.gov.


Instructions for Completing Form A 1. At the top left of the form enter your name(s), address(es) and phone number(s). If you have an e-mail

address(es), include that as well.

2. On the line labeled Plaintiff(s)/Appellant(s), type or print the plaintiff’s name(s). The plaintiff is the person orbusiness entity who files the complaint in a lawsuit. An appellant is the person or business entity requestingthe appeal. Business entities requesting a fee waiver are required to be represented by an attorney pursuant toRule 1:21-1(c).

3. On the line labeled Defendant(s)/Respondent(s), enter the name(s) of the defendants listed on the complaint.The defendant is the person or business entity being sued. A respondent is the person defending the appeal.

4. On the line labeled County, enter the county where the case is filed (only if applying for a fee waiver in theSuperior Court).

5. On the line labeled Docket Number, enter the docket number, if one has been assigned. This information canbe found if a complaint was served on you or if an appeal has been filed.

6. Enter your name(s) on the line that says “I/We, , am/are the” and then select the appropriate box where it says “plaintiff(s)/appellant(s)/defendant(s)/respondent(s) in the above-captioned matter.)”

7. In item #2, select the appropriate box as to whether or not you are an inmate on the line that says “I/We(am/am not/are/are not) an inmate in State prison or County Jail.”

8. For item #3, select the appropriate box(es) if you have been determined eligible for Public Assistance and/orSocial Security Disability. You must provide your most recent award statement as proof of eligibility.

Attach copies of all requested information as indicated on this form. You must include the last three digits ornumbers of any documents referenced below. However, you must also certify that you have removed orblacked out the remaining numbers or digits (confidential personal identifiers) from any of the followingdocuments filed with the court:

• Social Security numbers,• driver’s license numbers,• vehicle plate numbers,• insurance policy numbers,• active financial account numbers or• active credit card numbers.

Do not redact (black out) any information in the original papers that you are keeping (such as a bank statement) since you may have to show them to the court at some point.

9. For item #4, enter the number of dependents you support, if applicable. Do not include yourself.

10. In item #5, select the box where is says “I/we am/am not/are/are not claimed as a dependent…”.

11. Enter your employer’s name and information in the box that says “Employer’s Name, Address and TelephoneNumber.”

12. Fill in the financial information requested in the box. The judge requires your asset information and howmuch money you receive monthly from all sources.

13. Date, print and sign your name. Note: When you sign this form, you are certifying that the statements madeon the form are true. If you willfully make false statements, you may be subject to punishment.


NOTICE: This is a public document. Do not enter personal identifying information on it, such as your full Social Security number, driver’s license number, insurance policy number, vehicle plate number or active financial account or credit card number. This document as submitted will be available to the public upon request.

Name Address

Telephone Number Email Address

Court of New Jersey County (if applicable)

, Docket Number:

Certification/Petition/Application in Support of a Fee Waiver

Plaintiff(s)/Appellant(s),

v.

, Defendant(s)/Respondent(s).

I/We, , am/are the ( plaintiff(s)/ appellant(s)/ defendant(s)/ respondent(s)) in the above-captioned matter and I/we make this certification in support of my/our request for a filing fee waiver pursuant to Rule 1:13-2 or Rule 2:7-1.

1. I/We am requesting this relief because I/we do not have sufficient funds or assets with which to paythe filing fees associated with this action.

2. I/We, am/ am not/ are/ are not an inmate in State prison or County Jail.*

*Attachments necessary: If you are a state prison or county jail inmate, you must attach acertified copy of your prisoner’s fund account statement from the appropriate correctionalinstitution for the six months immediately preceding the date of this application. If you arerequesting a waiver of the partial filing fee requirement set forth in N.J.S.A. 30:4-16.3, youmust attach an affidavit of special circumstances.

3. I have been determined to be eligible for one or more of the following: (Check applicable boxes)

Public Assistance (please provide your most recent award statement as proof of eligibility); Social Security Disability (please provide your most recent award statement as proof of eligibility)

4. Below is an accurate and full disclosure of my financial situation. I financially supportdependents (not including myself). (A dependent is an individual who is a child or relative whoresides in the home and relies you for more than half of his/her support for any given calendar year)

Attachments necessary:Provide two months of documentation for the following:

• Welfare, Public Assistance, Unemployment, Disability, Social Security, ChildSupport/Alimony, other income.

Provide six months of bank statements for the following: • All bank accounts.


5. I/we am/ am not/ are/ are not claimed as a dependent on someone else’s tax return

Employer’s Name, Address and Telephone Number:

Complete the Following Information: Net Monthly Income $ House(s)/Land Market Value $ Spousal/Cohabitant Contribution $ Value of All Motor Vehicles $ Unemployment/Disability $ Cash $ Social Security $ Current Balance Checking Accts. $ Veterans Administration $ Current Balance Savings Accts. $ Pension $ Civil Judgment Awards/Pending $ Public Subsidies $ Current Value of Stocks/Bonds $ Child Support/Alimony $ Face Value of CDs/IRAs/401Ks $ Housing Subsidies $ Money Market Accounts $ Trust Fund Income $ Retrievable Bail Amt. & Location $ Income from Rental Properties $

Other Assets $ Total Monthly Income $ Total Assets $

6. I/We understand that I/we am/are under a continuing obligation to notify the court of a change in myfinancial situation

Certification

I/We certify that the foregoing statements made by me/us are true. I/We am/are aware that if any of the foregoing statements made by me/us are willfully false, I/we am/are subject to punishment.

I/We further certify that in accordance with Court Rule 1:38-7(b) all confidential personal identifiers have been redacted and that subsequent papers submitted to the court will not contain confidential personal identifiers.

Date Print your name(s)

Signature(s)


Instructions for Completing Form B 1. At the top left of the form enter your name(s), address(es) and phone number(s). If you have an e-

mail address(es), include that as well.

2. On the line labeled Plaintiff(s)/Appellant(s), type or print the plaintiff’s name. The plaintiff is theperson or business entity who files the complaint in a lawsuit. An appellant is the person or businessentity requesting the appeal. Business entities, other than sole proprietorships, requesting a feewaiver are required to be represented by an attorney pursuant to Rule 1:21-1(c).

3. On the line labeled Defendant(s)/ Respondent(s) enter the name(s) of the defendants listed on thecomplaint. The defendant is the person or business entity being sued. A respondent is the persondefending the appeal.

4. On the line labeled County, enter the county where the case is filed (only in the Superior Court.)

5. On the line labeled Docket Number, enter the docket number, if one has been assigned. Thisinformation can be found if a complaint was served on you or if an appeal has been filed.

6. Enter your name(s) and if you are the plaintiff(s)/appellant(s) or defendant(s)/respondent(s) on theline that says “application of(plaintiff(s)/appellant(s)/defendant(s)/respondent(s)).”

7. DO NOT fill out anything that appears under the text “For Court Use Only.” The judge willcomplete the remaining information.


NOTICE: This is a public document. Do not enter personal identifying information on it, such as your full Social Security number, driver’s license number, insurance policy number, vehicle plate number or active financial account or credit card number. This document as submitted will be available to the public upon request.

Name Address

Telephone Number Email Address

Court of New Jersey County (if applicable)

, Docket Number:

Order Waiving Filing Fees

Plaintiff(s)/Appellant(s),

v.

, Defendant(s)/Respondent(s).

This matter having been brought before the court on application of , ( plaintiff(s)/ appellant(s)/ defendant(s)/ respondent(s)) for an Order waiving filing fees pursuant to Rule 1:13-2 or Rule 2:7-1, and the Court having considered the moving party’s financial information, the matter and for good cause appearing:

(Do not write below this line, For Court Use Only)

It is on this day of , 20 , ORDERED that the application for a fee waiver is

Granted Denied

Revised to be effective September 1, 2017. CN: 10482 (Court Rules Appendix V) Page 1 of 10

Appendix V Family Part Case Information Statement

This form and attachments are confidential pursuant to Rules 1:38-3(d)(1) and 5:5-2(f) Attorney(s): Office Address: Tel. No./Fax No. Attorney(s) for:

SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION, FAMILY PART

Plaintiff, COUNTY vs.

DOCKET NO. Defendant. CASE INFORMATION STATEMENT

OF

NOTICE: This statement must be fully completed, filed and served, with all required attachments, in accordance with Court Rule 5:5-2 based upon the information available. In those cases where the Case Information Statement is required, it shall be filed within 20 days after the filing of the Answer or Appearance. Failure to file a Case Information Statement may result in the dismissal of a party’s pleadings.

INSTRUCTIONS:

The Case Information Statement is a document which is filed with the court setting forth the financial details of your case. The required information includes your income, your spouse's/partner's income, a budget of your joint life style expenses, a budget of your current life style expenses including the expenses of your children, if applicable, an itemization of the amounts which you may be paying in support for your spouse/partner or children if you are contributing to their support, a summary of the value of all assets referenced on page 8 – It is extremely important that the Case Information Statement be as accurate as possible because you are required to certify that the contents of the form are true. It helps establish your lifestyle which is an important component of alimony/spousal support and child support.

The monthly expenses must be reviewed and should be based on actual expenditures such as those shown from checkbook registers, bank statements or credit card statements from the past 24 months. The asset values should be taken, if possible, from actual appraisals or account statements. If the values are estimates, it should be clearly noted that they are estimates.

According to the Court Rules, you must update the Case Information Statement as your circumstances change. For example, if you move out of your residence and acquire your own apartment, you should file an Amended Case Information Statement showing your new rental and other living expenses.

It is also very important that you attach copies of relevant documents as required by the Case Information Statement, including your most recent tax returns with W-2 forms, 1099s and your three (3) most recent paystubs.

If a request has been made for college or post-secondary school contribution, you must also attach all relevant information pertaining to that request, including but not limited to documentation of all costs and reimbursements or assistance for which contribution is sought, such as invoices or receipts for tuition, board and books; proof of enrollment; and proof of all financial aid, scholarships, grants and student loans obtained.

FORM 4H


Part A - Case Information: Issues in Dispute: Date of Statement Cause of Action Date of Divorce, Dissolution of Civil Union or Termination of Domestic Partnership (post-Judgment matters)

Custody Parenting Time Alimony

Date(s) of Prior Statement(s) Child Support Equitable Distribution

Your Birthdate Counsel Fees Birthdate of Other Party Anticipated College/Post- Date of Marriage, or entry into Civil Union or Domestic Partnership

Secondary Education Expenses Other issues (be specific)

Date of Separation Date of Complaint Does an agreement exist between parties relative to any issue? Yes No.

If Yes, ATTACH a copy (if written) or a summary (if oral).

1. Name and Addresses of Parties:Your NameStreet Address City State/Zip Other Party’s NameStreet Address City State/Zip

2. Name, Address, Birthdate and Person with whom children reside:a. Child(ren) From This Relationship

Child’s Full Name Address Birthdate Person’s Name

b. Child(ren) From Other Relationships

Child’s Full Name Address Birthdate Person’s Name

Part B - Miscellaneous Information: 1. Information about Employment (Provide Name & Address of Business, if Self-employed)Name of Employer/Business Address

Name of Employer/Business Address

2. Do you have Insurance obtained through Employment/Business? Yes No. Type of Insurance:

Medical Yes No; Dental Yes No; Prescription Drug Yes No; Life Yes No; Disability Yes No

Other (explain)

Is Insurance available through Employment/Business? Yes No

Explain:

3. ATTACH Affidavit of Insurance Coverage as required by Court Rule 5:4-2 (f) (See Part G)


4. Additional Identification: Confidential Litigant Information Sheet: Filed Yes No

5. ATTACH a list of all prior/pending family actions involving support, custody or Domestic Violence, with the Docket Number, County, State and the disposition reached. Attach copies of all existing Orders in effect.

Part C. - Income Information: Complete this section for self and (if known) for other party. If W-2 wage earner, gross earned income refers to Medicare wages.

1. Last Year’s Income

Yours Joint Other Party 1. Gross earned income last calendar (year) $ $ $

2. Unearned income (same year) $ $ $

3. Total Income Taxes paid on income (Fed., State, F.I.C.A., and S.U.I.). If Joint Return, use middle column.

$ $ $

4. Net income (1 + 2 - 3) $ $ $

ATTACH to this form a corporate benefits statement as well as a statement of all fringe benefits of employment. (See Part G)

ATTACH a full and complete copy of last year’s Federal and State Income Tax Returns. ATTACH W-2 statements, 1099’s, Schedule C’s, etc., to show total income plus a copy of the most recently filed Tax Returns. (See Part G) Check if attached: Federal Tax Return State Tax Return W-2 Other

2. Present Earned Income and Expenses

Yours Other Party (if known)

1. Average gross weekly income (based on last 3 pay periods – ATTACH pay stubs) Commissions and bonuses, etc., are:

$ $

included not included* not paid to you. *ATTACH details of basis thereof, including, but not limited to, percentage overrides, timing of payments, etc. ATTACH copies of last three statements of such bonuses, commissions, etc.

2. Deductions per week (check all types of withholdings): $ $ Federal State F.I.C.A. S.U.I. Other

3. Net average weekly income (1 - 2) $ $

3. Your Current Year-to-Date Earned Income Provide Dates: From To 1. GROSS EARNED INCOME: $ Number of Weeks 2. TAX DEDUCTIONS: (Number of Dependents: ) a. Federal Income Taxes a. $ b. N.J. Income Taxes b. $ c. Other State Income Taxes c. $ d. F.I.C.A. d. $ e. Medicare e. $ f. S.U.I. / S.D.I. f. $ g. Estimated tax payments in excess of withholding g. $ h. h. $ i. i. $

TOTAL $


3. GROSS INCOME NET OF TAXES $ $

4. OTHER DEDUCTIONS If mandatory, check box a. Hospitalization/Medical Insurance a. $b. Life Insurance b. $c. Union Dues c. $d. 401(k) Plans d. $e. Pension/Retirement Plans e. $f. Other Plans - specify f. $g. Charity g. $h. Wage Execution h. $i. Medical Reimbursement (flex fund) i. $j. Other: j. $

TOTAL $

5. NET YEAR-TO-DATE EARNED INCOME: $

NET AVERAGE EARNED INCOME PER MONTH: $

NET AVERAGE EARNED INCOME PER WEEK $

4. Your Year-to-Date Gross Unearned Income From All Sources(including, but not limited to, income from unemployment, disability and/or social security payments, interest, dividends,

rental income and any other miscellaneous unearned income)

Source How often paid Year to date amount $ $ $

$ $ $ $ $ $

TOTAL GROSS UNEARNED INCOME YEAR TO DATE $

5. Additional Information:1. How often are you paid?

2. What is your annual salary? $

3. Have you received any raises in the current year? Yes No If yes, provide the date and the gross/net amount.

4. Do you receive bonuses, commissions, or other compensation, including distributions, taxable or non-taxable, in addition to your regular salary?

Yes No

If yes, explain:

5. Does your employer pay for or provide you with an automobile (lease or purchase), automobile expenses,gas, repairs, lodging and other.

Yes No

If yes, explain.:


6. Did you receive bonuses, commissions, or other compensation, including distributions, taxable or non-taxable, in addition to your regular salary during the current or immediate past 2 calendar years?

Yes No

If yes, explain and state the date(s) of receipt and set forth the gross and net amounts received:

7. Do you receive cash or distributions not otherwise listed? Yes No If yes, explain.

8. Have you received income from overtime work during either the current or immediate past calendar year? Yes No If yes, explain.

9. Have you been awarded or granted stock options, restricted stock or any other non-cash compensation or entitlement during the current or immediate past calendar year?

Yes No

If yes, explain.

10. Have you received any other supplemental compensation during either the current or immediate past calendar year?

Yes No

If yes, state the date(s) of receipt and set forth the gross and net amounts received. Also describe the nature of any supplemental compensation received.

11. Have you received income from unemployment, disability and/or social security during either the current or immediate past calendar year?

Yes No

If yes, state the date(s) of receipt and set forth the gross and net amounts received.

12. List the names of the dependents you claim:

13. Are you paying or receiving any alimony? Yes No If yes, how much and from or to whom?

14. Are you paying or receiving any child support? Yes No If yes, list names of the children, the amount paid or received for each child and to whom paid or from whom

received.

15. Is there a wage execution in connection with support? Yes No If yes explain.

16. Does a Safe Deposit Box exist and if so, at which bank? Yes No

17. Has a dependent child of yours received income from social security, SSI or other government program during either the current or immediate past calendar year?

Yes No

If yes, explain the basis and state the date(s) of receipt and set forth the gross and net amounts received

18. Explanation of Income or Other Information:


Part D - Monthly Expenses (computed at 4.3 wks/mo.) Joint Marital or Civil Union Life Style should reflect standard of living established during marriage or civil union. Current expenses should reflect the current life style. Do not repeat those income deductions listed in Part C – 3.

Joint Life Style Family, including

children

Current Life Style Yours and

children SCHEDULE A: SHELTER

If Tenant: Rent ............................................................................................................... $ $ Heat (if not furnished) ................................................................................... $ $ Electric & Gas (if not furnished) .................................................................. $ $ Renter’s Insurance ........................................................................................ $ $ Parking (at Apartment) .................................................................................. $ $ Other charges (Itemize) ................................................................................. $ $

If Homeowner: Mortgage ........................................................................................................ $ $ Real Estate Taxes (if not included w/mortgage payment) ........................... $ $ Homeowners Ins. (if not included w/mortgage payment) ........................... $ $ Other Mortgages or Home Equity Loans ...................................................... $ $ Heat (unless Electric or Gas) ......................................................................... $ $ Electric & Gas ............................................................................................ $ $ Water & Sewer ............................................................................................ $ $ Garbage Removal .......................................................................................... $ $ Snow Removal .............................................. $ $ Lawn Care ..................................................................................................... $ $ Maintenance/Repairs ............................................................................ $ $ Condo, Co-op or Association Fees .......................................................... $ $ Other Charges (Itemize) ................................................................................ $ $

Tenant or Homeowner: Telephone ...................................................................................................... $ $ Mobile/Cellular Telephone ............................................................................ $ $ Service Contracts on Equipment ................................................................. $ $ Cable TV ...................................................................................................... $ $ Plumber/Electrician ....................................................................................... $ $ Equipment & Furnishings ............................................................................. $ $ Internet Charges ............................................................................................. $ $ Home Security System .............................................. $ $ Other (itemize) $ $

TOTAL $ $ SCHEDULE B: TRANSPORTATION

Auto Payment ................................................................................................ $ $ Auto Insurance (number of vehicles: ) .............................................. $ $ Registration, License ..................................................................................... $ $ Maintenance ................................................................................................. $ $ Fuel and Oil ................................................................................................. $ $ Commuting Expenses ................................................................................... $ $ Other Charges (Itemize) ............................................................................... $ $

TOTAL $ $


SCHEDULE C: PERSONAL Joint Life Style Family, including

children

Current Life Style Yours and

children Food at Home & household supplies ............................................................... $ $ Prescription Drugs .............................................................................................. $ $ Non-prescription drugs, cosmetics, toiletries & sundries ............................... $ $ School Lunch .................................................................................................... $ $ Restaurants ........................................................................................................ $ $ Clothing ............................................................................................................. $ $ Dry Cleaning, Commercial Laundry ............................................................... $ $ Hair Care ........................................................................................................... $ $ Domestic Help .................................................................................................. $ $ Medical (exclusive of psychiatric)* ................................................................. $ $ Eye Care* .......................................................................................................... $ $ Psychiatric/psychological/counseling* ............................................................ $ $ Dental (exclusive of Orthodontic* ................................................................... $ $ Orthodontic* ..................................................................................................... $ $ Medical Insurance (hospital, etc.)* .................................................................. $ $ Club Dues and Memberships ........................................................................... $ $ Sports and Hobbies ........................................................................................... $ $ Camps ............................................................................................................... $ $ Vacations .......................................................................................................... $ $ Children’s Private School Costs ....................................................................... $ $ Parent’s Educational Costs ............................................................................... $ $ Children’s Lessons (dancing, music, sports, etc.) ........................................... $ $ Babysitting ........................................................................................................ $ $ Day-Care Expenses .......................................................................................... $ $ Entertainment .................................................................................................... $ $ Alcohol and Tobacco ....................................................................................... $ $ Newspapers and Periodicals ............................................................................. $ $ Gifts .................................................................................................................. $ $ Contributions .................................................................................................... $ $ Payments to Non-Child Dependents ................................................................ $ $ Prior Existing Support Obligations this family/other families (specify) ...................... $ $ Tax Reserve (not listed elsewhere) ................................................................. $ $ Life Insurance ......................................................................................... $ $ Savings/Investment ................................................................................ $ $ Debt Service (from page 7) (not listed elsewhere) ................................. $ $ Parenting Time Expenses ....................................................................... $ $ Professional Expenses (other than this proceeding) ................................ $ $ Pet Care and Expenses ............................................................................... $ $ Other (specify) ................................ $ $

*unreimbursed only

TOTAL $ $ Please Note: If you are paying expenses for a spouse or civil union partner and/or children not reflected in this budget, attach a schedule of such payments. Schedule A: Shelter ................................................................................................. $ $ Schedule B: Transportation .................................................................................... $ $ Schedule C: Personal ............................................................................................... $ $

Grand Totals ............................................................................................................ $ $


Part E - Balance Sheet of All Family Assets and Liabilities Statement of Assets

Description Title to

Property (P, D, J)1

Date of purchase/acquisition. If claim that asset is exempt,

state reason and value of what is claimed to be exempt

Value $ Put * after exempt

Date of Evaluation

Mo./Day/ Yr.

1. Real Property

2. Bank Accounts, CD’s (identify institution and type of account(s))

3. Vehicles

4. Tangible Personal Property

5. Stocks, Bonds and Securities (identify institution and type of account(s))

6. Pension, Profit Sharing, Retirement Plan(s), 40l(k)s, etc. (identify each institution or employer)

7. IRAs

8. Businesses, Partnerships, Professional Practices

9. Life Insurance (cash surrender value)

10. Loans Receivable

11. Other (specify)

TOTAL GROSS ASSETS: $ TOTAL SUBJECT TO EQUITABLE DISTRIBUTION: $

TOTAL NOT SUBJECT TO EQUITABLE DISTRIBUTION: $

1 P = Plaintiff; D = Defendant; J = Joint


Statement of Liabilities

Description

Name of Responsible

Party (P, D, J)

If you contend liability should not be shared, state reason

Monthly Payment

Total Owed Date

1. Real Estate Mortgages

2. Other Long Term Debts

3. Revolving Charges

4. Other Short Term Debts

5. Contingent Liabilities

TOTAL GROSS LIABILITIES: $ (excluding contingent liabilities)

NET WORTH: $ (subject to equitable distribution)

TOTAL SUBJECT TO EQUITABLE DISTRIBUTION: $ TOTAL NOT SUBJECT TO EQUITABLE DISTRIBUTION: $


Part F - - Statement of Special Problems Provide a Brief Narrative Statement of Any Special Problems Involving This Case: As example, state if the matter involves complex valuation problems (such as for a closely held business) or special medical problems of any family member, etc.

Part G - Required Attachments

Check If You Have Attached the Following Required Documents

1. A full and complete copy of your last federal and state income tax returns with all schedules and attachments. (Part C-1)

2. Your last calendar year’s W-2 statements, 1099’s, K-1 statements.

3. Your three most recent pay stubs.

4. Bonus information including, but not limited to, percentage overrides, timing of payments, etc.; the last three statementsof such bonuses, commissions, etc. (Part C)

5. Your most recent corporate benefit statement or a summary thereof showing the nature, amount and status of retirementplans, savings plans, income deferral plans, insurance benefits, etc. (Part C)

6. Affidavit of Insurance Coverage as required by Court Rule 5:4-2(f) (Part B-3)

7. List of all prior/pending family actions involving support, custody or Domestic Violence, with the Docket Number,County, State and the disposition reached. Attach copies of all existing Orders in effect. (Part B-5)

8. Attach details of each wage execution (Part C-5)

9. Schedule of payments made for a spouse or civil union partner and/or children not reflected in Part D.

10. Any agreements between the parties.

11. An Appendix IX Child Support Guideline Worksheet, as applicable, based upon available information.

12. If a request has been made for college or post-secondary school contribution, all relevant information pertaining to thatrequest, including but not limited to documentation of all costs and reimbursements or assistance for which contributionis sought, such as invoices or receipts for tuition, board and books; proof of enrollment; and proof of all financial aid,scholarships, grants and student loans obtained. A list of the information as promulgated by the Administrative Directorof the Courts can be found on the Judiciary website.

I certify that, other than in this form and its attachments, 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).

I certify that the foregoing information contained herein is true. I am aware that if any of the foregoing information contained therein is willfully false, I am subject to punishment.

DATED: SIGNED:

Where to File Your Responsive Pleadings Atlantic County Superior Court, Chancery Division, Family Part Atlantic County Civil Courthouse Family Intake 1201 Bacharach Blvd., West Wing Atlantic City, NJ 08401 (609) 594-3320

Bergen County Superior Court, Chancery Division, Family Part Bergen County Justice Center, Finance Division 10 Main Street, Room 119 Hackensack, NJ 07601 (201) 527-2300

Burlington County Superior Court, Chancery Division, Family Part Burlington County Central Processing Office Attention: Dissolution Intake Court Facility, 3rd Floor 49 Rancocas Road Mount Holly, NJ 08060 (609) 518-2645

Camden County Superior Court, Chancery Division Hall of Justice, 2nd Floor 101 South 5th Street Camden, NJ 08103-4001 (856) 379-2200, Ext. 3626

Cape May County Hand Delivery: Superior Court, Chancery Division, Family Part 9 North Main Street Cape May Court House, NJ 08210 Mailing Address: Superior Court, Chancery Division, Family Part 4 Moore Road Cape May Court House, NJ 08210 (609) 463-6607

Cumberland County Superior Court of New Jersey Finance Unit Cumberland County Courthouse 60 West Broad Street Bridgeton, NJ 08302 (856) 453-4534

Essex County Superior Court, Chancery Division, Family Part Family Division – Dissolution Unit Wilentz Justice Complex, 1st Floor, Room 113 212 Washington Street Newark, NJ 07102 (973) 693-6710

Gloucester County Gloucester County Justice Complex Family Division 1 North Broad Street Woodbury, NJ 08096 (856) 853-3200

Hudson County Superior Court, Chancery Division, Family Part Hudson Fee Office 595 Newark Avenue, 2nd Floor Jersey City, NJ 07306 (201) 795-6636

Hunterdon County Superior Court, Chancery Division, Family Part Family Case Management Office Hunterdon County Justice Center 65 Park Avenue Flemington, NJ 08822 (908) 237-5800

Mercer County Superior Court, Chancery Division, Family Part Mercer County Civil Courthouse 175 S. Broad Street, 2nd Floor P.O. Box 8068 Trenton, NJ 08822 (609) 571-4000

Middlesex County Hand Delivery: Family Division Superior Court of New Jersey Middlesex Vicinage 120 New Street New Brunswick, NJ 08901 (732) 519-3242, 3223Mailing Address:Family DivisionSuperior Court of New JerseyMiddlesex VicinageP.O. Box 2691New Brunswick, NJ 08903-2691(732) 519-3242, 3223

Where to File Your Responsive Pleadings Monmouth County Filing with Fee: Superior Court of New Jersey Monmouth Vicinage Courthouse Family Division P.O. Box 1260 Freehold, NJ 07728-1260 Filing without Fee: Superior Court of New Jersey Monmouth Vicinage Courthouse Family Division P.O. Box 1252 Freehold, NJ 07728 (732) 677-4302

Morris County Filing with Fee: Superior Court of New Jersey Morris County Courthouse Finance Division Office P.O. Box 929 Morristown, NJ 07963-0929 Filing without Fee: Superior Court of New Jersey Morris County Courthouse Finance Division Office P.O. Box 910 Morristown, NJ 07963-0929 (973) 656-4362

Ocean County Superior Court of New Jersey Ocean County Justice Complex Family Division, Room 210 120 Hooper Avenue P.O. Box 2191 Toms River, NJ 08753 (732) 929-2037

Passaic County Passaic County Superior Court Chancery Division, Family Part Matrimonial Unit County Administration Building, 8th Floor 401 Grand Street Paterson, NJ 07505 (973) 247-8537

Salem County Superior Court, Chancery Division, Family Part Salem County Courthouse 92 Market Street Salem, NJ 08079 (856) 935-7510

Somerset County Superior Court of New Jersey Family Case Management Office Somerset Courthouse, 2nd Floor P.O. Box 3000 Somerville, NJ 08876-1262 (809) 231-7600

Sussex County Superior Court of New Jersey Sussex County Judicial Center Finance Department 43-47 High Street Newton, NJ 07860 (973) 579-0630

Union County Mailing Address: Superior Court of New Jersey, Union County Family Division, Matrimonial Intake Unit 2 Cherry Street Elizabeth, NJ 07207 (908) 659-3314Hand Delivery:Superior Court of New Jersey, Union CountyFamily DivisionNew Annex Building2Cherry Street 3rd Floor, Intake UnitElizabeth. NJ 07207

Warren County Filing with Fee: Superior Court of New Jersey Central Fee Office 413 Second Street P.O. Box 400 Belvidere, NJ 07823-1500 (908) 475-6969Filing without Fee:Superior Court, Chancery Division, Family PartFamily Dissolution UnitCourthouse413 Second StreetP.O. Box 900Belvidere, NJ 07823-1500(908) 475-6167

FORM 4I

Name: ____________________________ Address: __________________________ __________________________________ Phone Number: ____________________

Date: _____________________________

County Family Part Superior Court of New Jersey Room 111, 1st FloorWilentz Justice Complex212 Washington StreetNewark, NJ 07102

Re: ____________________ v. ____________________ Docket Number: FM-_________________________

Dear Sir/Madam:

Enclosed are the original and one copy of the following documents. Each document that is enclosed is checked below

� Answer or � Answer and Counterclaim � Certification and Verification of Non-Collusion � Certification of Insurance � Rule 5:4-2(h) Certification by Self-Represented Litigant � Confidential Litigant Information Sheet � Filing Fee or � Filing Fee Waiver Request

Kindly file same and return a filed copy to me in the enclosed self-addressed stamped envelope.

Thank you for your prompt attention to this matter.

Kindest regards,

________________________________, Defendant Pro Se Encl.

P.O. Box 32040 | Newark, NJ 07102 - Volunteer Lawyers for Justice

Documents

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