State of New York Court of Claims ______________________________, Claimant, Affidavit in Support of Application Pursuant to CPLR 1101 (d) v. Claim No. The State of New York, ______________________________, Defendant(s). State of New York ) ) ss: County of ______________ ) I, _______________________________, being duly sworn, hereby declare as follows: 1) I am the claimant in the above-entitled proceeding, I am not an inmate in a federal, state or local correctional facility and I submit this affidavit in support of my application for a waiver of the filing fee pursuant to CPLR 1101(d). 2) I currently receive income from the following sources (check appropriate boxes): Salary or wages (state employers name and address and amount of take-home salary or wages: ) _______________________________________________________________ Public assistance (amount): ________________________________________________ Social Security / SSI (amount): _____________________________________________ Other (source and amount): ________________________________________________ 3) In the past twelve months, I have received money from the following sources: Business, profession or other self-employment Rent payments, interest or dividends Pensions, annuities or life insurance payments Disability or workers’compensation payments Gifts or inheritances yes yes yes yes yes no no no no no (If your answer to any of the above is “ yes,”describe each source of money and state the amount received and what you expect to continue to receive) (over): 2001 © American LegalNet, Inc. ________________________________________________________________________ ________________________________________________________________________ 4) (check appropriate box): I do not own any cash or bank accounts. I own cash and bank accounts with a total value of _________________. 5) I own the following property (real estate, bonds, stocks, securities, automobiles or any other property): NONE List property: Value: ____________________________ ___________________ ____________________________ ___________________ ____________________________ ___________________ 6) The following persons are dependent on me for their support (state name of dependent, your relationship and how much you contribute to their support. If none, state “ none.” ): _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 7) I have no savings, property, assets or income other than as set forth herein. 8) I am unable to pay the filing fee necessary to prosecute this proceeding. 9) No other person who is able to pay the filing fee has a beneficial interest in the result of this proceeding. 10) The facts of my case are described in my claim and other papers filed with the court. 11) I have made no prior request for this relief in this case. ________________________________________ (signature) Sworn to before me this ___ day of __________, ________. ___________________________ Notary Public 2001 © American LegalNet, Inc.