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Affidavit Of Appellant In Support Of Application For Permission To Proceed As Poor Person With Assigned Counsel Form. This is a New York form and can be use in Appellate Division Appellate Courts.
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Tags: Affidavit Of Appellant In Support Of Application For Permission To Proceed As Poor Person With Assigned Counsel, New York Appellate Courts, Appellate Division
AFFIDAVIT OF APPELLANT IN SUPPORT
OF APPLICATION FOR PERMISSION TO PROCEED AS A
POOR PERSON WITH ASSIGNED COUNSEL
NOTE: An intentionally false answer to any of the questions in this stateme nt could
result in your prosecution for the crime of perjury.
, being du ly sworn, d eposes an d says that the answe rs to the
questions in this affidavit are true, an d that he/sh e* know s that the inform ation is
being furnished for the purpose of enabling the court to determine whether or not
he/she* is e ntitled to m aintain an appea l as a poor pe rson with a ssigned co unsel.
1.
What is your full name, age and date of birth?
2.
What is your home address & phone number?
3.
If you were represented by retained counsel in the court b elow, state the name and
address of the person w ho paid h is/her* fee an d the am ount?
4.
If you have been released on bail, what was the amount of the bail and give the name
and address of the person w ho furnishe d the colla teral for your bail bond and the
name and add ress of the person who paid the premium on the bond?
5.
6.
Are you single, married, separated or divorced?
(a) If married, what is the name of your spouse?
(b) What are the first names and ages of your children?
7.
What is your occupation?
If you are e mploy ed, wha t is your we ekly
salary and the name and address of your employer?
8.
If you are a student, indicate the school which you attend and the name and address
of the person who is paying your tuition, room and board?
9.
(a) If your spouse is employed, what is her/his* weekly salary and name and
address of h er/his* em ployer?
(b) If you are no t living with y our spouse or children, what are their addresses and
how m uch do y ou contrib ute we ekly to the ir support?
* Strike ou t whiche ver is not app licable.
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10.
(a)
(b)
(c)
Do you or your spouse have any bank accounts in your individual names or
jointly with each other or any other person?
Do you hav e any insu rance po licies, stocks, bonds, trust accounts or any
other investments in your name, or jointly in your name and any other person?
If your answ er to either (a) or (b) of this question was "Yes", describe the
asset, the location and amount in any bank account and the value of any other
asset.
11.
If you or yo ur spouse o wn au tomob iles, what is the year and mode l, monthly
paym ents if financed, to whom are payments made and what are the number of
remaining payments?
12.
Do you own your own home or do you rent?
13.
What is the approxim ate market value, present mortgage balance, name of bank or
other financing institution and monthly payments on any home owned by you in your
own name, your spouse's name or jointly with your spouse or any other person?
14.
Do you hav e any oth er assets not co vered by the prece ding que stions in this
statement?
15.
My M onthly inc ome a nd expe nses are as follo ws:
INCOME
My Sa lary..............................................
My spo use's earnin gs................................
Other income of mine or any member
of my im media te family...........................
TOTA L INC OME ...................................
EXPENSES
Rent or m ortgage p ayme nt.........................
Food....................................................
Utilities (Hea t, Telepho ne, W ater, Electric).....
Autom obile exp ense.................................
Premiums on Life or Medical
Insurance p olicies...............................
2002 © American LegalNet, Inc.
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Repa ymen t of loans..................................
Name of Creditor and amou nt.....................
.....................
.....................
...... ...............
.....................
TOTA L EXP ENSE S........................
15.
Do you authorize the Court to make any inquiries or investigation concerning the
answers given to you in this affidavit?
16.
If the answ ers in this questionn aire are not in your handwriting, were the questions
and answers read to you and are your answers true?
Your Sign ature
(PRINT name, address & phone #)
Swor n to befor e me this
,
.
of
day
Notary Public
Form Revised 3/2/98
2002 © American LegalNet, Inc.
