State of New York Court of Claims ______________________________, DIN No. _______________, Claimant, Affidavit in Support of Application Pursuant to CPLR 1101 (f) v. Claim No. The State of New York, Defendant. 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 an inmate in a federal, state or local correctional facility (state place of incarceration: _____________________), and I submit this affidavit in support of my application for a reduction of the filing fee pursuant to CPLR 1101(f). 2) I currently receive income from the following sources, exclusive of correctional facility wages: _____________________________________________________________ _____________________________________________________________ 3) I own the following valuable property (other than miscellaneous personal property): NONE List property: Value: ____________________________ ___________________ ____________________________ ___________________ ____________________________ ___________________ ____________________________ ___________________ 4) I have no savings, property, assets or income other than as set forth herein. 2001 © American LegalNet, Inc. 5) I am unable to pay the filing fee necessary to prosecute this proceeding. 6) No other person who is able to pay the filing fee has a beneficial interest in the result of this proceeding. 7) The facts of my case are described in my claim and other papers filed with the court. 8) I have made no prior request for this relief in this case. ________________________________________ (signature) Sworn to before me this ___ day of __________, ________. ____________________________ Notary Public AUTHORIZATION I, _______________________, inmate number _____________________, request and authorize the agency holding me in custody to send to the Clerk of the Court of Claims certified copies of the correctional facility trust fund account statement (or the institutional equivalent) for the past six months. I further request and authorize the agency holding me in custody to deduct the filing fee from my correctional facility trust fund account (or the institutional equivalent) and to disburse those amounts as instructed by the Court of Claims. This authorization is furnished in connection with the above entitled case and shall apply to any agency into whose custody I may be transferred. I UNDERSTAND THAT THE ENTIRE FILING FEE AS DETERMINED BY THE COURT OF CLAIMS WILL BE PAID IN INSTALLMENTS BY AUTOMATIC DEDUCTIONS FROM MY CORRECTIONAL FACILITY TRUST FUND ACCOUNT EVEN IF MY CASE IS DISMISSED. __________________________________________ (signature) 2001 © American LegalNet, Inc.