Civil Court of the City of New York County of Index Number Part In the Matter of the Application of AFFIDAVIT IN SUPPORT OF AN APPLICATION TO PROCEED AS A POOR PERSON AND TO WAIVE COURT FEES to prosecute as a poor person against State of New York, County of ss: , being duly sworn, deposes and says: PRINT YOUR NAME 1. I am the party named as in the above titled action. 2. 1 reside at 3. 1 seek to proceed in the above titled action. 4. 1 have a good and meritorious cause of action in that 5. 1 request that an Order be granted: waiving any and all statutory fees for the defense or prosecution of the action, waiving the fee for the filing of a Notice of Appeal other (Specify) 6. 1 make this application based on CPLR 1101. I do not have, nor am I able to obtain, the funds needed to pay the court fees. I will be unable to proceed unless the Order is granted. 7. 1 am/am not a recipient of Public Assistance from the Department of S ocial Services of the City of New York. 8. 1 have no income other than the sum of $ per from 9. 1 own no property of any kind except necessary personal wearing appar el and [Indicate other property and the value of such property] 10. No other person is beneficially interested in the recovery sought. 11. a) I have not made a previous application for this or similar relief. b) I have made previous application(s) for this or similar relief, bu t I am making this further application because . Sign your name Print your address Sworn to before me this day of 20 Signature of Court Employee and Title Telephone Number CIV-GP-15-i(Revised 5/04) American LegalNet, Inc. www.USCourtForms.com