Free Poor Person's Relief - New York


File Size: 17.9 kB
Pages: 1
File Format: PDF
State: New York
Category: Small Claims
Word Count: 311 Words, 1,742 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.courts.state.ny.us/courts/nyc/smallclaims/forms/PoorPersonsRelief.pdf

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Preview Poor Person's Relief
Civil Court of the City of New York
County of Part In the Matter of the Application of Index Number 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 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

in the above titled action.

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 ยง1101. 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 Social 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 apparel 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, but 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)
FREE CIVIL COURT FORM No fee may be charged to fill in this form. Form can be found at: http://www.nycourts.gov/courts/nyc/smallclaims/forms.shtml.