FILED: RENSSELAER COUNTY CLERK 08/09/2021 11:28 AM
`NYSCEF DOC. NO. 5
`
`REQUEST FOR JUDICIAL INTERVENTION
`Rensselaer Supreme COURT, COUNTY OF Rensselaer
`
`INDEX NO. EF2021-269598
`
`RECEIVED NYSCEF: 08/09/2021
`UCS-840
`(rev. 07/29/2019)
`
`Date Index Issued:
`Index No:
`Enter the complete case caption. Do not use et al or et ano. If more space is needed, attach a caption rider sheet.
`
`For Court Use Only:
`IAS Entry Date
`
`CAPTION
`T. T.
`
`-against-
`HOOSIC VALLEY CENTRAL SCHOOL DISTRICT
`
`Plaintiff(s)/Petitioner(s)
`
`Judge Assigned
`
`RJI Filed Date
`
`Defendant(s)/Respondent(s)
`
`NATURE OF ACTION OR PROCEEDING: Check only one box and specify where indicated.
`COMMERCIAL
`MATRIMONIAL
`☐ Contested
`☐ Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.)
`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):
`NOTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202.70(d),
`complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C).
`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).
`
`TORTS
`Asbestos
`Child Victims Act
`Environmental (specify):
`Medical, Dental, or Podiatric Malpractice
`Motor Vehicle
`Products Liability (specify):
`Other Negligence (specify):
`Other Professional Malpractice (specify):
`Other Tort (specify):
`
`☐☒☐☐☐☐☐☐☐
`
`☐
`
`Commercial
`
`Block:
`
`Lot:
`
`☐
`
`☐☐
`
`Tax Certiorari - 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
`☐ Pistol Permit Revocation Hearing
`☐ 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
`☒ ☐
`☐ ☒
`☐ ☒
`Check one box only and enter additional information where indicated.
`
`SPECIAL PROCEEDINGS
`☐ CPLR Article 75 (Arbitration)     [see NOTE in COMMERCIAL section]
`☐ CPLR Article 78 (Body or Officer)
`☐ Election Law
`☐ Extreme Risk Protection Order
`☐ MHL Article 9.60 (Kendra's Law)
`☐ MHL Article 10 (Sex Offender Confinement-Initial)
`☐ MHL Article 10 (Sex Offender Confinement-Review)
`☐ MHL Article 81 (Guardianship)
`☐ Other Mental Hygiene (specify):
`☐
`Other Special Proceeding (specify):
`
`08/09/2021
`
`If yes, date filed:
`If yes, date served:
`If yes, judgment date:
`
`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
`Poor Person Application
`Request for Preliminary Conference
`Residential Mortgage Foreclosure Settlement Conference
`Writ of Habeas Corpus
`Other (specify):
`
`☐ ☐☐☐☐ ☐☒ ☐☐☐☐☐
`
`☐
`
`Date Issue Joined:
`Relief Requested:
`Relief Requested:
`Relief Requested:
`Relief Requested:
`
`Return Date:
`Return Date:
`Return Date:
`
`Miscellaneous
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`FILED: RENSSELAER COUNTY CLERK 08/09/2021 11:28 AM
`NYSCEF DOC. NO. 5
`
`INDEX NO. EF2021-269598
`
`RECEIVED NYSCEF: 08/09/2021
`
`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).
`Index/Case Number
`Court
`
`Judge (if assigned)
`
`Relationship to instant case
`
`Case Title
`
`PARTIES:
`Parties
`List parties in same order as listed in the
`caption and indicate roles (e.g., plaintiff,
`defendant; 3rd party plaintiff, etc.)
`Name: T., T.
`
`Un-
`Rep
`
`☐
`
`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/or Unrepresented Litigants
`Issue Joined
`Insurance
`For represented parties, provide attorney's name, firm name, address, phone
`For each defendant,
`For each defendant,
`and email. For unrepresented parties, provide party's address, phone and
`indicate if issue has
`indicate insurance
`email.
`been joined.
`carrier, if applicable.
`ALEXANDRA SLATER, HERMAN LAW, 1800 N MILITARY TRL
`STE 160 , BOCA RATON, FL 33431,
`aslater@hermanlaw.com
`
`Role(s): Plaintiff/Petitioner
`
`☒ YES ☐ NO
`
`☒
`
`☐
`
`☐
`
`☐
`
`☐
`
`☐
`
`☐
`
`☐
`
`☐
`
`Name: HOOSIC VALLEY CENTRAL
`SCHOOL DISTRICT
`Role(s): Defendant/Respondent
`
`2 Pleasant Avenue, Schaghticoke, NY 12154
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`Name:
`
`Role(s):
`
`☐ YES ☒ NO
`
`☐ YES ☐ NO
`
`☐ 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:
`
`08/09/2021
`
`5116470
`Attorney Registration Number
`
`This form was generated by NYSCEF
`
`ALEXANDRA DOROTHY SLATER
`Signature
`
`ALEXANDRA DOROTHY SLATER
`Print Name
`
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