STATE OF NEW YORK SUPREME COURT, APPELLATE DIVISION THIRD JUDICIAL DEPARTMENT P.O. BOX 7288, CAPITOL STATION ALBANY, NY 12224 INSTRUCTIONS FOR MOVING FOR PERMISSION TO PROCEED ON APPEAL AS A POOR PERSON ____________________________________________________________________________________ 1) At the top of the attached form is a Notice of Motion. The title of the case should be placed on the left hand side of the form and it should be written as the title appeared on the order or judgment appealed from. This is the caption. Below the caption is a sentence which begins "Please take notice...". The first date to be filled in is the date the attached affidavit in support of the motion was notarized. The second date to be filled in is the return date of the motion, which should be a Monday after service of the motion papers upon all parties as described in paragraph 2 below. The motion papers should be served on all parties (if a party is represented by an attorney, service of a copy should be made upon the attorney and if a party is represented by the Office of the Attorney General, service of a copy should be made upon that office), and on the County Attorney of the County in which the papers from the lower court were filed. If service of the motion papers is done by personal delivery, the motion should be made returnable on a Monday at least eight (8) days after such service. If service of the motion papers is done by mail, the motion should be made returnable on a Monday at least thirteen (13) days after the motion papers are mailed. As soon as possible after service of copies of the motion papers, the original motion papers, as well as proof that you have served the motion papers on the other parties and the County Attorney, should be forwarded to this office. If the motion is being made in connection with an appeal to this Court, you should also attach to the motion papers a copy of the order or judgment being appealed from, the decision, if any, upon which the order or judgment was based, and a copy of the notice of appeal. THERE WILL NOT BE ORAL ARGUMENT ON THE RETURN DATE OF THE MOTION. 2) 3) 4) Revised: February 19, 2014 1 American LegalNet, Inc. www.FormsWorkFlow.com Please fill in the underlined spaces in the following form. Return the original to this Court, forward one copy to each of your adversaries, forward one copy to the County Attorney, and keep one for your records. STATE OF NEW YORK APPELLATE DIVISION SUPREME COURT THIRD DEPARTMENT , , Notice of Motion for Permission to Proceed as Poor Person on Appeal v , . Index No.: PLEASE TAKE NOTICE that, upon the annexed affidavit sworn to on the , 20 , 20 , a motion will be made to this Court, on the , in the City of Albany, New York for an order granting the day of day of appellant/petitioner permission to proceed as a poor person. Dated: (Signature) (Print Name) (Address) (Your name, address and telephone number) DIN # (if applicable) (Telephone) PLEASE TAKE NOTICE that, pursuant to section 800.2 (a) of the Rules of this Court, this motion will be submitted on the papers, and the personal appearance of counsel or the parties is neither required nor permitted. Revised: February 19, 2014 2 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT IN SUPPORT OF MOTION STATE OF NEW YORK COUNTY OF 1. What is your full name? ss.: 2. What is the nature of the above-entitled action or proceeding? 3. In the event you have taken an appeal to this Court, what is the order or judgment you have appealed from to this Court? (Please attach hereto a copy of the order or judgment appealed from, the decision, if any, upon which the order or judgment is based, and a copy of your notice of appeal.) 4. a. An order or judgment has been entered in the Court Clerk's Office on , 20 . , 20 Yes . No b. c. A copy of that order or judgment was served on me on Have you filed a copy of any notice of appeal in the County Clerk's office? If yes, when? d. If yes, have you served a copy of the notice of appeal on the respondent(s)? Yes No If yes, when? e. Were you represented by counsel? Counsel's name and address: f. 5. Was counsel assigned or retained? If you were represented by retained counsel in the court below, state the name and address of the person who paid his/her* fee and the amount. Revised: February 19, 2014 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. What relief are you seeking by this motion? 7. What facts are present to support your contention that there is merit to your appeal (Attach additional documentation, if necessary.) 8. Are you able to pay the costs, fees and expenses necessary to maintain the appeal? 9. Are you: Single Married Separated Divorced What is your occupation? If you are a student, indicate the school which you attend and the 10. name and address of the person who is paying your tuition, room and board. 11. Are you are employed? Yes No If yes, please state your weekly salary and provide the name and address of your employer. Please provide a copy of your most recent pay stub. If married and your spouse is employed, what is his/her weekly gross salary and the name and 12. address of his/her employer? 13. Do you receive support from anyone? Yes No If yes please provide the name, relationship, address and the amount of support provided to you. Revised: February 19, 2014 4 American LegalNet, Inc. www.FormsWorkFlow.com 14. Do you support anyone? Yes No If yes, please provide the name, relationship, address and the amount of support you provide. 15. Do you own real estate either by yourself or with someone else? If yes please provide the following information: a. Other owner(s) (if any): Yes No b. Location (street address, mailing address; Town, County, State): c. d. Current value, including improvements: Existing mortgages and/or liens (Attach additional sheet if required): 1. Name of bank, mortgagee or lien holder: 2. Balance due: 16. List the location and amount of any savings or checking accounts held in your name or jointly with others (Attach additional sheet if required): Location (Bank) Type Owners Balance 17. List any stocks, bonds, trusts or cash on hand owned by you in which you have any benefit and give the type, location and value of each (Attach additional sheet if required): 18. Revised: Please state the year, make model and value of any motor vehicle(s) owned by you and the February 19, 2014 5 American LegalNet, Inc. www.FormsWorkFlow.com amount of any existing loan(s): 19. Do you have any other asse