COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : Motion and Affidavit for Plaintiff(s) to Appeal In JUDICIAL SUBPOENA Permission Forma Pauperis Form 4. -against- : Motion and Affidavit for Permission to Appeal In Forma Pauperis : : v. Appeal No. Defendant(s) : ...................................................... District Court or Agency No. Affidavit in Support of Motion Instructions THE PEOPLE OF THE STATE OF NEW YORK I swear or affirm under penalty of perjury that, because of TOmy poverty, I cannot prepay the docket fees of my appeal or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct. (28 U.S.C. § 1746; 18 U.S.C. § 1621.) Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is “0,” “none,” or “not applicable (N/A),” write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case’s docket number, and the question number. GREETINGS: WE COMMAND YOU, that all business and __________________________________________ __________________________________________ excuses being laid aside, you and each of you attend before , the__ Honorable at the Court __ located at County of Signature Date in room , on the day of , 20 , at o'clock in the noon, and at any recessed orMy issues ondate, toare: adjourned appeal testify and give evidence as a witness in this action on the part of the 1. For both you and your spouse estimate the average amount of money received from of court and will make you liable to Your failure to comply with this subpoena is punishable as a contempt each of the following sources during whose 12 months. subpoena was issued for received weekly, biweekly, quarterly, damages sustained as a the party on the past behalf this Adjust any amount that was a maximum penalty of $50 and all semiannually, or result annually failure to comply. rate. Use gross amounts, that is, amounts before any deductions for taxes or of your to show the monthly otherwise. Witness, Honorable Income source Court in County, Average monthly amount during the past 12 months day of , 20 You Employment $ ,Amount expected nextof the one of the Justices month Spouse $ You $ Spouse $ (Attorney must sign above and type name below) Self-employment $ $ Income from real property (such as rental income) $ $ Interest and dividends $ $ $ $ Gifts $ $ $ $ Alimony $ $ Office and $ P.O. Address $ Child support $ $ $ $ (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis $ Attorney(s)$for Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: $ $ Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Retirement (such as social security, pensions, annuities, -against- $ insurance Disability (such as social security, insurance payments) Unemployment payments Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA : $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ : $ $ $ : $ Defendant(s) : . . .Public-assistance.(such. as. welfare) . . $ . . . . . . . . . . . . $ . . . . . . . . . . ............ ... . ...... . . Other (specify):__________________ $ THE PEOPLE OF THE STATE OF NEW YORK Total monthly income: $ TO List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) 2. Employer Dates of Employment Address Gross Monthly Pay $ GREETINGS: $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before $ , the Honorable at the Court County ofyour spouse’s employmentlocated at history, most recent employer first. (Gross monthly pay is before taxes or other 3. List in room day of , 20 , at o'clock in the noon, and at any recessed deductions.) , on the or adjourned date, to testify and give evidence as a witness in this action on the partof the of Dates Gross Employer Address Employment Monthly Pay $ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to $ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a $ result of your failure to comply. 4. How much cash do you and your spouse have? $___________________________________ Witness, Honorable , one of the institution. Below, state any money you or your spouse have in bank accounts or in any other financial Justices of the Court in County, Financial institution day of , 20 Amount you have Type of account $ Amount your spouse has $ (Attorney must sign above and type name below) $ $ $ $ Attorney(s) for If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account. 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household Office and P.O. Address furnishings. (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. Other Real Estate (Value) : Home (Value) Motor Vehicle #1 (Value) JUDICIAL SUBPOENA Plaintiff(s) -against- Make and year: : Model: : Registration No: : Home (Value) Other Real Estate (Value) Motor Vehicle #2 (Value) Defendant(s) : ...................................................... Make and year: Model: Registration No: THE PEOPLE OF THE STATE OF NEW YORK 6. TO State every person, business, or organization owing you or your spouse money, and the amount owed. Amount owed to you Person(s) owing you or your spouse money Amount owed to your spouse $ $ $ $ GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before $ $ , the Honorable at the Court located at County of 7. State the persons who rely on you or your spouse for support. in room , on the day of , 20 , at o'clock in the noon, and at any recessed Name Relationship Age or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 8. Estimate the average monthly expenses was issued for a maximum penalty of amounts all by your spouse. the party on whose behalf this subpoena of you and your family. Show separately the $50 and paiddamages sustained as a result Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. of your failure to comply. Amount expected next month You Spouse , one of the Justices of the Expenses Witness, Honorable Court in or home-mortgage payment (includeof rented for mobile County, day lot , 20 Rent home) Are real-estate taxes included? Is property insurance included? YES YES NO NO $ $ $ $ $ $ Food $ $ Clothing $ $ Utilities (electricity, heating fuel, water, sewer, and telephone) Home maintenance (repairs and upkeep) Laundry and Dry Cleaning Medical and dental expenses (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis (Attorney must sign above and type name below) Attorney(s) for Office $ P.O. Address $ and $ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: $ Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Transportation (not including motor vehicle payments) Plaintiff(s) : Recreation, entertainment,-againstnewspapers, magazines, etc. : Insurance (not deducted from wages or included in Mortgage payments): Calendar No. $ $ JUDICIAL SUBPOENA : $ $ : $ $ Defendant(s) Life : ...................................................... $ $ Health $ $ Motor Vehicle $ $ $ $ $ $ Homeowner’s or renter’s THE PEOPLE OF THE STATE OF NEW YORK Other: TO Taxes (not deducted from wages or included in Mortgage payments) (specify): GREETINGS: payments Installment WE COMMAND YOU, that all business and excuses being laid aside, you and $ each of you attend before Motor Vehicle $ , the Honorable at the Court Credit card (name): $ $ located at County of in room Department ,Store (name): day of on the , 20 , at o'clock in the noon, and at any recessed $ $ or adjourned date, to testify and give evidence as a witness in this action on the part of the Other: $ $ Alimony, maintenance, and support paid to others $ $ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Regular expenses for operation of business, profession, the party on whose behalf this subpoena was issued for a maximum penalty of $50 and $ damages sustained as a all or farm (attach detailed statement) $ result of your failure to comply. Other (specify): $ Witness, Honorable Total monthly expenses: Court in County, day of 9. $ $ , one of the Justices of the $ , 20 Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? YES NO (Attorney must sign above and type name below) If yes, describe on an attached sheet. 10. Have you paid - or will you be paying- an attorney any money for services in connection with this case, including the completion of this form? Attorney(s) for YES NO If yes, how much? $ If yes, state the attorney's name, address, and telephone number: Office and P.O. Address (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : 11. Have you paid — or will you be paying — anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? : YES NO If yes, how much? If yes, state the person’s name, address, and telephone number: $ : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK 12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal. TO 13. State the address of your legal residence. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your daytime phone number: Your age: Your years of schooling: Your social-security to comply with this subpoena is punishable as a contempt of court and will make you liable to Your failure number: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 5 of 5 American LegalNet, Inc. www.USCourtForms.com