1 2 3 4 5 6 -against7 , Defendant. At the Supreme Court of the State of New York, held in and for the County of at the County Courthouse at , New York, on the day of PRESENT: HON. Justice of the Supreme Court -----------------------------------------------------------------X In the Matter of the Application of , Plaintiff, For Permission to Prosecute an Action as a Poor Person Index No.: POOR PERSON ORDER -----------------------------------------------------------------X 8 9 10 Upon the annexed affidavit of And it being alleged that said Plaintiff action or claim based upon **DRL § 170 subd. , has a good cause of , and that he/she is unable to pay the costs, fees and expenses to prosecute this action, and that there is no other person beneficially interested in the action, thereof 11 12 13 NOW on motion of ORDERED that , Plaintiff, it is hereby is permitted to prosecute this action as a poor and it is further person against ORDERED that any recovery by Judgment or Settlement in favor of Plaintiff shall be paid to the Clerk of the Court to await distribution pursuant to court order, and it is further ORDERED that the Clerk of this Court is directed to make no charge for costs or fees in connection with the prosecution of this action, including one (1) certified copy of the judgment. E N T E R: 14 J.S.C. **Insert the grounds for the divorce: DRL §170(1) - cruel and inhuman treatment DRL §170(2) - abandonment separation DRL §170(3) - confinement in prison DRL §170(4) - adultery DRL §170(5) - living apart one year after separation decree or judgment of DRL §170(6) - living apart one year after execution of a separation agreement (Appendix - Rev. 5/99) 2001 © American LegalNet, Inc.