COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : : Plaintiff(s) -againstCircuit Court for Calendar No. JUDICIAL SUBPOENA Case No. : City or County : Name Name Street Address City State VS. Apt. # Zip Code ( .................................. Plaintiff :Street Address ) Defendant(s) Area Code .... Telephone :City ................ Apt. # State ( Zip Code Defendant ) Area Code Telephone REQUEST FOR WAIVER OF PREPAYMENT OF THE FILING FEE (DOM REL 32) THE PEOPLE OF THE STATE OF NEW YORK I, TO , representing myself, wish to file the complaint, petition or other paper(s) entitled which I have completed and attached. I am unable to prepay the filing fee because of poverty. The answers to the following questions are true: 1. (a) Do you have any money? GREETINGS: How much? Where? Savings Account (bank’s name, account number and balance) WE COMMANDAccountthat allname, account number and balance) laid aside, you and each of you attend before Checking YOU, (bank’s business and excuses being , the Honorable at the Court (b) Are you employed? Where? located at County of Position in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, How muchandyou make?(specifyas a witness two this action onand the amount) the to testify do give evidence monthly, every in weeks, or weekly the part of (c) Are you self-employed? Doing what? How much do you make? (specify monthly, every two weeks, or weekly and the amount) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (d) If you are not working, when did you last work? the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a (e) Do to comply. Make, Model and Year result of your failure you own an automobile? Is it paid for? _____ How much do you owe? To whom? Witness, Honorableowe you any money? ____ How much? _________ To whom? ( name, address & tel. #. ) , one of the Justices of the (f) Does anyone Court in County, day of , 20 (g) Do you own real estate or a house? _______ Value Is it mortgaged? _____ Total owed ____________ Monthly payment (Attorney must sign above and type name below) (h) Do you receive any rental income? How much? (i) Do you own any personal property (excluding ordinary household furnishings and clothing)? What is it? Attorney(s) for (j) Do you receive money from social security, supplemental security income (SSI), worker’s compensation or other disability benefits, public assistance, food stamps, settlements, judgments, trust funds, retirement, annuity or pension payments? If so, how much and what is the source? Office and P.O. Address (k) Do you have any investments? What and how much? Telephone No.: Interest income (specify monthly or annual) ___________ DividendNo.: Facsimile income (specify monthly or annual) ___________ E-Mail Address: Mobile Tel. No.: Page 1 of 2 DR32 - Revised 10 April 2003 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : : Plaintiff(s) Calendar No. JUDICIAL SUBPOENA (l) Do you owe money to others (e.g., rent, credit card debts, loan payments, etc)? -against: How much? To whom? (name, address & tel.#) : (m) If you are married and living with your spouse, state his/her name. Does your spouse work?_______ His/Her annual income : Doing what and where? Defendant(s) : . . . . . . . . . . . .(n) .List. persons. whom. you. actually support, .your . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . relationship to them and the amount you pay in support. (specify monthly or weekly) THE PEOPLE OF THE STATE OF NEW YORK TO 2. Other facts (if any) concerning your inability to prepay the filing fee are: GREETINGS: PRISON INMATES OR THOSE ON WORK RELEASE MUST ANSWER THE WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ADDITIONAL QUESTIONS BELOW , the Honorable at the Court located at County of 3. What is your inmate number? _____________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed 4. date, to filed any other cases in state or witness in this action on the part of case or adjourned Have youtestify and give evidence as afederal court? _____If yes, then for each the state who you sued, the case number and the result of the case. (Attach additional page if more space is needed) 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. 5. Do you have a prison job or other assignment? ______ Employer, assignment and wages Witness, Honorable Court in County, , one of the Justices of the day of , 20 6. Do you have a prison inmate account? ______ What is your account number?____________________________ How much money is in your prison inmate account? Attach a certified copy of your inmate account (Attorney must sign above least the last two (2) months. statement(s) for at and type name below) For these reasons, I request waiver of prepayment of the filing fee. I solemnly affirm on personal knowledge and under Attorney(s) for the penalties of perjury that the contents of the foregoing paper are true. (Date) (Signature) Office and P.O. Address (Address) (City, State, Zip) (Tel. #) Telephone No.: (_________)_________________________________ Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 2 of 2 DR32 - Revised 10 April 2003 American LegalNet, Inc. www.USCourtForms.com