APPLICATION FOR POOR PERSON STATUS AND ASSIGNMENT OF COUNSEL IN A CRIMINAL APPEAL DIRECTIONS: Completely fill in the blank spaces pertinent to your application. Failure to properly complete this application may result in its denial. Complete three (3) copies. File the original with this court. Serve one copy by mail on the appropriate District Attorney and keep the third copy for your records. Please make certain you have signed on each line under which the word ''Appellant'' appears on pages 4 and 5 and that you do so before a Notary Public. All applications/motions are returnable on a Monday (or if a Monday falls on a holiday, then the next business day). You must give at least 13 days notice (prior to the return date) if you serve your papers on the District Attorney (or other person entitled to notice) by mail, or 8 days if you use personal service and you must provide this office with an affidavit of service which also must be signed before a notary public. (A form for such is attached hereto as page 6.) ***** NEW YORK STATE SUPREME COURT APPELLATE DIVISION - THIRD DEPARTMENT: The People of the State of New York -against- Application For Poor Person Status and Assigned Counsel , (Please fill in your name) Appellant. : 1. What is your date of birth? 2. What is your current address? 3. What is your DIN (if assigned)? 4. This application is for: (Check all that apply) (a) Poor person status: (b) Assignment of counsel: (c) Other (state type of relief sought): 1 American LegalNet, Inc. www.FormsWorkflow.com 5. If you are appealing from a judgment of conviction and resulting sentence or resentence, were you convicted after a trial or convicted upon a plea of ? (Check only one.) guilty 6. Please provide the following information: (a) What crime(s) were you convicted of? (b) In what county were you convicted? (c) On what date were you sentenced? (d) Were two (2) copies of the notice of appeal filed with the appropriate County Clerk within thirty (30) days after imposition of your sentence or resentence? Yes No (e) Were you represented by an attorney? (f) If you answered ''yes '' what was his or her name? (g) If you answered ''yes'' was he or she assigned by the court? Yes (h) If your attorney was not assigned, please state the amount of the fee paid and the source of the payment, i.e. who paid the fee? Yes No No 7. If you are not appealing from a judgment of conviction and sentence or resentence, please state what you are appealing: 8. If ''yes" please state the amount Were you released on bail? Yes No and give the name of the person who provided the money or collateral and who paid the premium on the bond. ? (Check one) 9. Are you single 10. Do you receive support from anyone? Yes If ''yes'' please provide No the name, relationship to you, address, and amount of support he or she provides. ; married ; separated ; divorced 2 American LegalNet, Inc. www.FormsWorkflow.com 11. Are you employed? Yes If ''yes'' what is your weekly salary and No what is the name and address of your employer? 12. Do you support anyone? Yes If ''yes'' please provide the name, No relationship to you, address, and amount of support he or she is provided by you. 13. Do you own any real estate either by yourself or with someone else? Yes No 14. If your answer is ''yes'' please provide the following information: Other owner(s) (if any) (a) Location (street address; mailing address; Town; County; State) (b) (c) (d) Current value, including improvements Existing mortgages and/or liens: (Attach additional sheet if required) [i] Name of mortgagor or lien holder: [ii] 15. Balance due: List the location and amount of any savings or checking accounts in your name or held jointly with others: Location (Bank) Type Owners Balance 16. List any stocks, bonds, trusts or cash on hand owned by you or in which you have any benefit and give the type, location and value of each 17. Please state the year, make, model and estimated value of any motor vehicle(s) owned by you and the amount you owe on such vehicle(s), if anything 18. Do you own any other assets not covered by the above questions? Yes 3 No American LegalNet, Inc. www.FormsWorkflow.com 19. If your answer to the above was ''yes '' then please describe the asset and indicate its value: 20. My monthly income and expenses are as follows: INCOME My salary or wages My spouse's salary or wages Salary or wages of any other person in my household Other income received by me or my spouse or person in my household (Alimony; support; disability, etc.) TOTAL INCOME FROM ALL SOURCES EXPENSES Rent or mortgage payment Real property taxes, if any Food Utilities (Heat; Phone; Water; Electric; Cable) Automobile expenses Insurance Premiums (Life or medical) Total loan repayments (list below) Creditor Amount Other obligations, including alimony and/or support TOTAL EXPENSES 21. Do you authorize the Court to make any inquiries or investigation concerning the Yes answers given by you in this affidavit? No 22. If the answers above are not in your handwriting, were the questions and answers read Yes to you and are your answers true? No (Appellant) 4 American LegalNet, Inc. www.FormsWorkflow.com State of New York County of ) ) ss: , being duly sworn, deposes and says: I have read the foregoing application/motion and have answered each question truthfully and to the best of my knowledge and belief and understand that my answers will be used to determine my eligibility for poor person status and assignment of counsel (Appellant) Sworn to before me this of 20 day Notary Public (See next page for Affidavit of Service) 5 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT OF SERVICE BY MAILING State of New York County of ) ) ss: , being duly sworn, deposes and says: I have (Fill in name) served a true copy of this application on the District Attorney of County on the day of (month), 20 (Fill in name of county) (year) by mailing same in a sealed, properly addressed envelope, with prepaid postage, in a post-office or official depository of the U.S. Postal Service within the State of New York. Signature Sworn to before me this day of 20 Notary Public 6 American LegalNet, Inc. www.FormsWorkflow.com