`RECEIVED NYSCEF: 07/31/2023
`NYSCEF DOC. NO. 17
`Request for Judicial Intervention Addendum
`UCS-840A (7/2012)
`Index No:
`Supreme COURT, COUNTY OF Schenectady
`For use when additional space is needed to provide party or related case information.
`
`INDEX NO. 2023-83
`
`2023-83
`
`PARTIES:
`For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in "Attorneys" space.
`Parties
`Attorneys and Unrepresented Litigants
`Issue Joined
`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,
`caption and indicate roles (e.g., plaintiff,
`and email. For unrepresented parties, provide party's address, phone and
`indicate if issue has
`defendant, 3rd party plaintiff, etc.)
`email.
`been joined.
`Name: Doe, John
`
`Role(s): Defendant/Respondent
`
`☐ YES ☒ NO
`
`☒
`
`Insurance Carriers
`For each defendant,
`indicate insurance
`carrier, if applicable.
`
`RELATED CASES:
`
`List any related actions. For Matrimonial actions, include any related criminal and/or Famiy Court cases.
`
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