`JD-CV-116 Rev. 1-16
`
`STATE OF CONNECTICUT
`SUPERIOR COURT
`www.jud.ct.gov
`
`CSFLREQ
`*CSFLREQ*
`
`Instructions
`1. Fill out all sections and file with the court.
`2. File at least 3 days before the date of the scheduled event.
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`Name of case (First-named plaintiff v. First-named defendant)
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`Judicial District of
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`Name of Judge who scheduled the event (if applicable)
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`Note: If the request is granted, the court will try to schedule the
`event for the requested date. However, if that date is not
`available, it will be scheduled for the next available date.
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`Date of request
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`Docket number
`CV
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`Date of scheduled event (if applicable)
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`-
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`(S)
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`(“X” box(es) that apply and give reason(s) for request below)
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`Requested Action
`Status Conference on or about:
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`Date
`Client/adjuster to be available by phone for
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`.
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`Event
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`scheduled on
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`.
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`Date
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`Pretrial on or about
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`.
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`Date
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`Party to be excused from
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`Other:
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`Reason(s) for request:
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`Event
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`scheduled on
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`.
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`Date
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`.
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`I agree to notify my client and all counsel of record and self-represented parties whether the requested action is granted or
`denied, and if granted, the specific ruling of the court. I have told all counsel and self-represented parties of record that I
`would be asking for the requested action. All Counsel and Self-represented Parties:
`Consent
`Do not consent to the action requested above
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`Signed (Person making request)
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`Name of attorney and juris number or self-represented party (Print or type)
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`The person requesting the action is the:
`Plaintiff
`Firm name (If applicable)
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`Defendant
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`Attorney for Plaintiff
`Address
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`Attorney for Defendant
`Telephone number (with area code)
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`I certify that a copy of the above was mailed or delivered on the date shown below to all counsel and self-represented parties of record. A
`sheet is attached listing the name and address of each party the copy was mailed or delivered to.
`Signed (Individual attorney or self-represented party)
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`Date
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`Order
`Request is
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`Granted
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`Denied
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`Signed (Judge)
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`Date
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`ADA NOTICE
`The Judicial Branch of the State of Connecticut complies with the
`Americans with Disabilities Act (ADA). If you need a reasonable
`accommodation in accordance with the ADA, contact a court
`clerk or an ADA contact person listed at www.jud.ct.gov/ADA/
`
`