Written by attorney Robert Walter Dapelo

New York State Poor Person Affidavit

SUPREME COURT OF THE STATE OF NEW YORK 1 COUNTY OF -----------------------------------------------------------------X In the Matter of the Application of 2,3 , Index No.: Plaintiff. For Permission to Prosecute as a Poor Person AFFIDAVIT IN SUPPORT OF APPLICATION TO PROCEED - against - AS A POOR PERSON 4 , Defendant. ---------------------------------------------------------------X STATE OF NEW YORK } ss: 5 COUNTY OF } 6 , being duly sworn, says: 7 1. I reside at in the City, Town or Village of , County of , State of New York, and I have resided in the State of New York for the past years. 8 2. I am about to commence a lawsuit for divorce. This lawsuit is based upon **DRL ?170 - . 9 3. My sole source of income is: I earn $ per . 10 4. My property and its value are as follows: 11 5. I make this application pursuant to Section 1101 of the Civil Practice Law and Rules upon the ground that I am unable to pay costs, fees and expenses necessary to pursue my case and am unable to obtain the funds to do so, and unless an order is entered relieving me from the obligation to pay, I will be unable to prosecute my case. (Appendix - Rev. 5/99) 12 6. No other person is beneficially interested in the recovery sought herein. 13 7. No previous application for the same or similar relief has been made by me in this case except: . WHEREFORE, I respectfully ask for an order permitting me to prosecute an action as a poor person. The foregoing statements have been carefully read by the undersigned who states that they are true and correct. 14 Plaintiff Subscribed and sworn to before me on NOTARY PUBLIC **Insert the grounds for the divorce: DRL ?170(1) - cruel and inhuman treatment DRL ?170(4) - adultery DRL ?170(2) - abandonment DRL ?170(5) - living apart one year after separation decree or judgment of separation DRL ?170(3) - confinement in prison DRL ?170(6) - living apart one year after execution of a separation agreement

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