Please fill in the underlined spaces on the following form with answers appropriate to your motion. Motions are returnable in this Court on a Monday (or if a Monday falls on a holiday, on the next business day). You must give 13 days' notice (prior to the return date) if you serve your adversary (or adverseries) by mail or 8 days' notice if you use personal service. Return the original motion papers to this office, serve your adversary (or adversaries) with one copy, serve the County Attorney with one copy, and provide this office with proof of service. STATE OF NEW YORK SUPREME COURT APPELLATE DIVISION THIRD DEPARTMENT -----------------------------------------, , MOTION (BY RESPONDENT) FOR ASSIGNMENT OF COUNSEL Docket No. ________ -vs- , . -----------------------------------------PLEASE TAKE NOTICE that, upon the annexed affidavit, sworn to the day of , a motion will be made at a term of this Court to be held in City of Albany, New York, on the ____ day of __________________, for an order assigning counsel to respondent. Dated: (Signature) (Print Name) (Address) (Telephone) American LegalNet, Inc. www.FormsWorkflow.com -2 AFFIDAVIT IN SUPPORT OF MOTION STATE OF NEW YORK COUNTY OF ss.: __________________________, respondent in the above-entitled appeal, being duly sworn, deposes and says that the answers to the questions in this affidavit are true, and that he/she* knows that the information is being furnished for the purpose of enabling the court to determine whether or not he/she* is entitled to assignment of counsel. 1. What is your full name, age and date of birth? ___________________________________________________________________ ___________________________________________________________________ 2. What is your home address and telephone number? ___________________________________________________________________ ___________________________________________________________________ 3. Were you assigned counsel in lower court? ________________ (a) If the answer is "Yes", give name and address of the assigned attorney: ___________________________________________________________________ _________________________________________________________________ (b) Are you requesting that the attorney assigned to you in lower court be assigned to represent you in this Court? ________ 4. If you were represented by retained counsel in the court below, state the name and address of the person who paid his/her* fee and the amount? __________________________________________________________________ __________________________________________________________________ _____________ *Strike out whichever is not applicable. American LegalNet, Inc. www.FormsWorkflow.com -3 5. Are you single, married, separated or divorced? __________________________________________________________________ 6. (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 a student, indicate the school which you attend and the name and address of the person who is paying your tuition, room and board? __________________________________________________________________ _________________________________________________________________ 8. If you are employed, what is your weekly salary and the name and address of your employer? __________________________________________________________________ __________________________________________________________________ 9. (a) If your spouse is employed, what is his/her* weekly salary and name and address of his/her* employer? __________________________________________________________________ __________________________________________________________________ (b) If you are not living with your spouse or children, what are their addresses and how much do you contribute weekly to their support? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 10. (a) Do you or your spouse have any bank accounts in your individual names or jointly with each other or any other person? __________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com -4 (b) Do you have any insurance policies, stocks, bonds, trust accounts or any other investments in your name, or jointly in your name and any other person? __________________________________ (c) If your answer 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 your spouse own automobiles, what is the year and model, monthly payments, if financed, to whom payments are made and the number of remaining payments? ___________________ __________________________________________________________________ 12. Do you own your own home or do you rent? _______________ 13. What is the approximate 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 have any other assets not covered by the preceding questions in this statement? __________________________________________________________________ __________________________________________________________________ 15. My monthly income and expenses are as follows: INCOME: My salary....................................____________________ My spouse's earnings..........................____________________ Other income of mine or any member of my immediate family............____________________ TOTAL....................................____________________ EXPENSES: Rent or mortgage payment......................____________________ Food..........................................____________________ Utilities (heat, telephone, water, electric)..____________________ Automobile expenses..........................____________________ American LegalNet, Inc. www.FormsWorkflow.c