NYSCEF DOC. NO. 11
`
`REQUEST FOR JUDICIAL INTERVENTION
`Supreme COURT, COUNTY OF Nassau
`
`INDEX NO. 600662/2023
`
`RECEIVED NYSCEF: 02/15/2023
`UCS-840
`(rev. 02/01/2022)
`
`01/12/2023
`Date Index Issued:
`600662/2023
`Index No:
`CAPTION
`Enter the complete case caption. Do not use et al or et ano. If more space is needed, attach a caption rider sheet.
`Amanda Gross
`
`For Court Use Only:
`IAS Entry Date
`
`-against-
`Wantagh Fire Department, Wantagh Fire District, Kenneth Kelly Jr., Josef Seier
`
`Plaintiff(s)/Petitioner(s)
`
`Judge Assigned
`
`RJI Filed Date
`
`Defendant(s)/Respondent(s)
`
`☐
`
`Commercial
`
`If yes, date filed:
`If yes, date served:
`If yes, judgment date:
`
`01/12/2023
`01/26/2023
`
`Date Issue Joined:
`Relief Requested:
`Relief Requested:
`Relief Requested:
`Relief Requested:
`
`Dismiss
`
`02/28/2023
`
`Return Date:
`Return Date:
`Return Date:
`
`1 of 2
`
`Has a summons and complaint or summons with notice been filed?
`Has a summons and complaint or summons with notice been served?
`Is this action/proceeding being filed post-judgment?
`NATURE OF JUDICIAL INTERVENTION
`Infant's Compromise
`Extreme Risk Protection Order Application
`Note of Issue/Certificate of Readiness
`Notice of Medical, Dental or Podiatric Malpractice
`Notice of Motion
`Notice of Petition
`Order to Show Cause
`Other Ex Parte Application
`☐ Partition Settlement Conference
`Poor Person Application
`Request for Preliminary Conference
`Residential Mortgage Foreclosure Settlement Conference
`Writ of Habeas Corpus
`Other (specify):
`
`☐ ☐☐☒☐ ☐☐ ☐☐☐☐☐
`
`☐
`
`NATURE OF ACTION OR PROCEEDING:
`COMMERCIAL
`☐ Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.)
`☐ Contract
`☐ Insurance (where insurance company is a party, except arbitration)
`☐ UCC (includes sales and negotiable instruments)
`☐ Other Commercial (specify):
`NOTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202.70(d),
`complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C).
`TORTS
`☐ Adult Survivors Act
`Asbestos
`Environmental (specify):
`Medical, Dental or Podiatric Malpractice
`Motor Vehicle
`Products Liability (specify):
`Other Negligence (specify):
`Other Professional Malpractice (specify):
`Other Tort (specify): Assault and Battery
`SPECIAL PROCEEDINGS
`☐ Child-Parent Security Act (specify):
`☐ Assisted Reproduction☐ Surrogacy Agreement
`☐ CPLR Article 75 - Arbitration     [see NOTE in COMMERCIAL section]
`☐ CPLR Article 78 - Proceeding against a Body or Officer
`☐ Election Law
`☐ Extreme Risk Protection Order
`☐ MHL Article 9.60 - Kendra's Law
`☐ MHL Article 10 - Sex Offender Confinement (specify):
`☐ MHL Article 81 (Guardianship)
`☐ Other Mental Hygiene (specify):
`☐
`Other Special Proceeding (specify):
`STATUS OF ACTION OR PROCEEDING Answer YES or NO for every question and enter additional information where indicated.
`YES NO
`☒ ☐
`☒ ☐
`☐ ☒
`Check one box only and enter additional information where indicated.
`
`Check only one box and specify where indicated.
`MATRIMONIAL
`☐ Contested
`NOTE: If there are children under the age of 18, complete and attach the
`MATRIMONIAL RJI Addendum (UCS-840M).
`For Uncontested Matrimonial actions, use the Uncontested Divorce RJI (UD-13).
`REAL PROPERTY
`Specify how many properties the application includes:
`☐ Condemnation
`☐ Mortgage Foreclosure (specify): ☐ Residential
`Property Address:
`NOTE: For Mortgage Foreclosure actions involving a one to four-family, owner-
`occupied residential property or owner-occupied condominium, complete and
`attach the FORECLOSURE RJI ADDENDUM (UCS-840F).
`☐ Partition
`NOTE: Complete and attach the PARTITION RJI ADDENDUM (UCS-840P).
`☐
`Tax Certiorari (specify):
`Block:
`Lot:
`Section:
`Tax Foreclosure
`Other Real Property (specify):
`OTHER MATTERS
`☐ Certificate of Incorporation/Dissolution     [see NOTE in COMMERCIAL section]
`☐ Emergency Medical Treatment
`☐ Habeas Corpus
`☐ Local Court Appeal
`☐ Mechanic's Lien
`☐ Name Change/Sex Designation Change
`☐ Pistol Permit Revocation Hearing
`☐ Sale or Finance of Religious/Not-for-Profit Property
`☐ Other (specify):
`
`☐☐
`
`☐☐☐☐☐☐☐☒
`
`☐
`
`Initial
`
`☐
`
`Review
`
`

`

`NYSCEF DOC. NO. 11
`
`INDEX NO. 600662/2023
`
`RECEIVED NYSCEF: 02/15/2023
`
`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).
`Index/Case Number
`Court
`Judge (if assigned)
`
`Case Title
`
`Relationship to instant case
`
`PARTIES
`Parties
`List parties in same order as listed in the
`caption and indicate roles (e.g., plaintiff,
`defendant, 3rd party plaintiff, etc.)
`Name: Gross, Amanda
`
`Un-
`Rep
`
`☐
`
`Role(s): Plaintiff/Petitioner
`
`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).
`Attorneys and Unrepresented Litigants
`Issue Joined
`For represented parties, provide attorney's name, firm name, address, phone
`For each defendant,
`and email. For unrepresented parties, provide party's address, phone and
`indicate if issue has
`email.
`been joined.
`VESSELIN MITEV, Mitev Law Firm, PC, 1214 N. Country
`Road Stony Brook, NY 11790, Stony Brook, NY 11790,
`8887208377, vess@mitevlaw.com
`
`Insurance Carriers
`For each defendant,
`indicate insurance
`carrier, if applicable.
`
`☒ YES ☐ NO
`
`☐
`
`☐
`
`☒
`
`☒
`
`☐
`
`☐
`
`☐
`
`☐
`
`☐
`
`Name: Wantagh Fire Department
`
`Role(s): Defendant/Respondent
`
`Name: Wantagh Fire District
`
`Role(s): Defendant/Respondent
`
`Name: Kelly, Kenneth
`
`Role(s): Defendant/Respondent
`
`Name: Seier, Josef
`
`Role(s): Defendant/Respondent
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`CALI CHANDIRAMANI, Goldberg Segalla, 711 Third Avenue
`Suite 1900, New York, NY 10017, 646-292-8788,
`cchandiramani@goldbergsegalla.com
`
`☒ YES ☐ NO
`
`CALI CHANDIRAMANI, Goldberg Segalla, 711 Third Avenue
`Suite 1900, New York, NY 10017, 646-292-8788,
`cchandiramani@goldbergsegalla.com
`
`☒ YES ☐ NO
`
`Arch
`
`Arch
`
`☐ YES ☒ NO
`
`☐ YES ☒ NO
`
`☐ YES ☐ NO
`
`☐ YES ☐ NO
`
`☐ YES ☐ NO
`
`☐ YES ☐ NO
`
`☐ YES ☐ NO
`
`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:
`
`02/15/2023
`
`5300298
`Attorney Registration Number
`
`This form was generated by NYSCEF
`
`CALI LYNN CHANDIRAMANI
`Signature
`
`CALI LYNN CHANDIRAMANI
`Print Name
`
`2 of 2
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