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--- Page 1 --- Q Q QOQO OQ QQOQ Q QO O Q OQ O Q Q Q Q Q Q Q Q Q Q O Q Q Q O Q O Q Q @ Q Q @ Q @ QQQQQQ OOOOOO REQUEST FOR JUDICIAL INTERVENTION UCS-840 (rev. 12/16/2024) _______________ COURT, COUNTY OF _______________ 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 Plaintiff(s)/Petitioner(s) Judge Assigned -against- RJI Filed Date Defendant(s)/Respondent(s) NATURE OF ACTION OR PROCEEDING Check only one box and specify where indicated. COMMERICIAL MATRIMONIAL Business Entity (includes corporations, partnerships, LLCs, LLPs, etc.) Contested Contract NOTE: If there are children under the age of 18, complete and attach the Insurance (where insurance company is a party, except arbitration) MATRIMONIAL RJI ADDENDUM (UCS-840M). UCC (includes sales and negotiable instruments) For Uncontested Matrimonial actions, use the Uncontested Divorce RJI (UD-13). Other Commercial (specify): _______________________________________________ REAL PROPERTY Specify how many properties the application includes: _______ NOTE: For Commercial Division assignment requests pursuant to 22 NYCRR 202.70(d), Condemnation complete and attach the COMMERCIAL DIVISION RJI ADDENDUM (UCS-840C). Mortgage Foreclosure (specify): Residential Commercial TORTS Property Address: ____________________________________________________ Asbestos NOTE: For Mortgage Foreclosure actions involving a one to four-family, Environmental (specify): __________________________________________________ owner-occupied residential property or owner-occupied condominium, Medical, Dental or Podiatric Malpractice complete and attach the FORECLOSURE RJI ADDENDUM (UCS-840F). Motor Vehicle Partition Products Liability (specify): ________________________________________________ NOTE: Complete and attach the PARTITION RJI ADDENDUM (UCS-840P). Other Negligence (specify): ________________________________________________ Tax Certiorari (specify): Section:________ Block:________ Lot:________ Other Professional Malpractice (specify): _____________________________________ Tax Foreclosure Other Tort (specify): ______________________________________________________ Other Real Property (specify): __________________________________________ SPECIAL PROCEEDINGS OTHER MATTERS Child-Parent Security Act (specify): Assisted Reproduction Surrogacy Agreement Certificate of Incorporation/Dissolution [see NOTE in COMMERCIAL section] CPLR Article 75 – Arbitration [see NOTE in COMMERCIAL section] Emergency Medical Treatment CPLR Article 78 – Proceeding against a Body or Officer Habeas Corpus Election Law Local Court Appeal Extreme Risk Protection Order Mechanic’s Lien MHL Article 9.60 – Kendra’s Law Name Change/Sex Designation Change MHL Article 10 – Sex Offender Confinement (specify): Initial Review Pistol Permit Revocation Hearing MHL Article 81 (Guardianship) Sale or Finance of Religious/Not-for-Profit Property Other Mental Hygiene (specify): ____________________________________________ Other (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 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 Notice of Medical, Dental or Podiatric Malpractice Date Issue Joined: ___________________ Notice of Motion Relief Requested: ______________________________ Return Date: ___________________ Notice of Petition Relief Requested: ______________________________ Return Date: ___________________ Order to Show Cause Relief Requested: ______________________________ Return Date: ___________________ Other Ex Parte Application Relief Requested: ______________________________ Partition Settlement Conference Request for Preliminary Conference Residential Mortgage Foreclosure Settlement Conference Waiver of Court Costs, Fees, and Expenses Writ of Habeas Corpus Other (specify): ____________________________________________________________________________ SUPREME NEW YORK 161704 09/17/2026 JANE DOE, CORNELL UNIVERSITY, INC., CHI PHI CHAPTER HOUSE ASSOCIATION, CHI PHI FRATERNITY, INC., CHI PHI EDUCATIONAL TRUST, ALPHA BETA HOUSE CORPORATION OF DELTA DELTA DELTA, DELTA DELTA DELTA SORORITY, ZAREEN Sexual Assault 09/16/2026 Name Change 10/23/2026 FILED: NEW YORK COUNTY CLERK 09/30/2026 01:25 PM INDEX NO. 161704/2026 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 09/30/2026 1 of 3 --- Page 2 --- O O Q @ @ @ 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). Un- Rep Parties List parties in same order as listed in the caption and indicate roles (e.g., plaintiff, defendant, 3rd party plaintiff, etc.) Attorneys and Unrepresented Litigants For represented parties, provide attorney’s name, firm name, address, phone and email. For unrepresented parties, provide party’s address, phone and email. Issue Joined For each defendant, indicate if issue has been joined. Insurance Carriers For each defendant, indicate insurance carrier, if applicable. Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): YES NO Name: Role(s): 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: ___________________ _______________________________________________________ Signature ________________________________________________________ _______________________________________________________ Attorney Registration Number Print Name Jane Doe Plaintiff ETHAN COHEN, RHEINGOLD GIUFFRA RUFFO PLOTKIN & HELLMAN LLP 551 5TH AVE FL 29 NEW Cornell University, Inc. Defendant 373 Pine Tree Road, Ithaca, NY 14850 Chi Phi Chapter HouseAss Defendant P.O. Box 1600, Ithaca, NY 14850 Chi Phi Fraternity, Inc. Defendant 573 Main St. Geneva, NY 14456 Chi Phi Educational Trust Defendant 885 Woodstock Rd., Ste. 430-389 Roswell, GA 30075 Alpha Beta House Corpo Defendant 410 E UPLAND, ITHACA, NY14850 Delta Delta Delta Sorority Defendant 14951 Dallas Pkwy., Ste. 500 Dallas, TX 75254 Zareen Enterprise LLC d/ Defendant 409 EDDY ST., ITHACA, NY, 14850 Matthew Ingalls Defendant 48 TRILLIUM RD, FAIRFIELD, CT 06824 Johnathan Newell Defendant 12944 Stonebrook Dr. Davie, FL 33330 Winston Lee Defendant Cornell University- Martin Y. Tang Welcome Center 616 Th t A Ith NY 14853 Gillio Lopes Defendant 4402 Saul Rd. Kensington, MD 20895 Diego Sarabia Defendant 7 Short Dr. Bethel, CT 06801 Scott Norris Defendant 5540 Wells Curtice Rd. Canandaigua, NY 14424 Scott Ketzschmar Defendant 8814 Meisner Rd. Casco, MI 48064 09/30/2026 6213144 ETHAN J COHEN FILED: NEW YORK COUNTY CLERK 09/30/2026 01:25 PM INDEX NO. 161704/2026 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 09/30/2026 2 of 3 --- Page 3 --- Request for Judicial Intervention Addendum Index No: ________________________ COUNTY OF__________________________ _______________________COURT, For use when additional space is needed to provide party or related case information. For parties without an attorney, check "Un-Rep" box AND enter party address, phone number and e-mail address in "Attorneys" space. PARTIES: Insurance Carrier(s): (Y/N): Joined Issue Attorneys and/or Unrepresented Litigants: Parties: Rep Un- litigants, provide address, phone number and e-mail address. address of all attorneys that have appeared in the case. For unrepresented Provide attorney name, firm name, business address, phone number and e-mail 3rd-party plaintiff). indicate party role(s) (e.g. defendant; List parties in caption order and G YES First Name Last Name Last Name G Firm Name First Name G NO City Street Address Primary Role: e-mail Fax Phone Secondary Role (if any): G YES First Name Last Name Last Name G Firm Name First Name G NO City Street Address Primary Role: e-mail Fax Phone Secondary Role (if any): G YES First Name Last Name Last Name G Firm Name First Name G NO City Street Address Primary Role: e-mail Fax Phone Secondary Role (if any): G YES First Name Last Name Last Name G Firm Name First Name G NO City Street Address Primary Role: e-mail Fax Phone Secondary Role (if any): G YES First Name Last Name Last Name G Firm Name First Name G NO City Street Address Primary Role: e-mail Fax Phone Secondary Role (if any): G YES First Name Last Name Last Name G Firm Name First Name G NO City Street Address Primary Role: e-mail Fax Phone Secondary Role (if any): List any related actions. For Matrimonial actions, include any related criminal and/or Family Court cases. RELATED CASES: Relationship to Instant Case Judge (if assigned) Court Index/Case No. Case Title UCS-840A (7/2012) Zip State Zip State Zip State Zip State Zip State Zip State Supreme New York 161704/2026 Doe John Defendant Doe John Defendant Doe John Defendant Petito Orazio Defendant Petito Orazio 107 Jessup Rd Ithaca New York 14850 Print Form FILED: NEW YORK COUNTY CLERK 09/30/2026 01:25 PM INDEX NO. 161704/2026 NYSCEF DOC. NO. 22 RECEIVED NYSCEF: 09/30/2026 3 of 3