Free Affidavit in Support of an Application to Proceed as a Poor Person Authorizing the Stat - New York

CIVIL COURT OF THE CITY OF NEW YORK County of Part in the matter of the Application of

Index No.: AFFIDAVIT IN SUPPORT OF AN APPLICATION TO PROCEED AS A POOR PERSON AND AUTHORIZING THE STATE TO PAY THE COSTS FOR THE PRODUCTION OF A STENOGRAPHIC TRANSCRIPT
, being duly sworn, deposes and says:

to prosecute as a poor person against

State of New York, County of

ss:

1. I am the party named as 2. The case was tried before Judge

in the above titled action.

.

3. 1 request that an Order be granted: AUTHORIZING THE STATE TO PAY THE COSTS FOR THE STENOGRAPHIC TRANSCRIPT. The estimate* of the costs for the production of the transcript is $
[*Attach estimate(s) and total them if more than one.] If no Notice of' Appeal is to be filed, but a request for the State to pay the costs for the production of a transcript is being submitted, please state why the transcript is needed .

4. 1 make this application based on CPLR §1101. I do not have, nor am I able to obtain, the funds needed to file a Notice of Appeal and/or to pay for the stenographic transcript. I will be unable to proceed unless the Order is granted. 5. 1 am/am not a recipient of Public Assistance from the Department of Social Services of the City of New York.
(strike one).

6. 1 have no income other than the sum of $

per

from

.
7. 1 own no property of any kind except necessary personal wearing apparel and

.
8. No other person is beneficially interested in the recovery sought. 9. 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 Sworn to before me this day of 20 Sign your name Print your address Signature of Court Employee and Title

Telephone Number CIV-GP-16-i (Revised 1/04)
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/civil/forms.shtml.