Supreme Court of the State of New York Appellate Division: Second Judicial Department AFFIRMATION Appellate Division Docket No.: ________________________ State of New York ) County of _______________ ) ss.: I, ____________________________________, affirm under the penalties of perjury that: 1. 2. 3. 4. 5. WHEREFORE, I request that the court grant me the following relief: Dated: ________________ ____, 200__ ____________________________________ Affirmed before me this _____ day of _____________, 200__ ___________________________________ Notary Public 2002 � American LegalNet, Inc.