New York Poor Person Form – Fill Out and Use This PDF

STATE OF NEW YORK

SUPREME COURT, APPELLATE DIVISION

THIRD JUDICIAL DEPARTMENT

P.O. BOX 7288, CAPITOL STATION

ALBANY, NY 12224

INSTRUCTIONS FOR MOVING FOR PERMISSION TO PROCEED

AS A POOR PERSON AND FOR ASSIGNMENT OF COUNSEL ON A FAMILY COURT APPEAL

1)At the top of the attached form is a Notice of Motion. The title of the case should be placed on the left hand side of the form and it should be written as the title appeared on the order or judgment appealed from. This is the caption. Below the caption is a sentence which begins "Please take notice...". The first date to be filled in is the date the attached affidavit in support of the motion was notarized. The second date to be filled in is the return date of the motion, which should be a Monday after service of the motion papers upon all parties as described in paragraph 2 below.

2)The motion papers should be served on all parties (if a party is represented by an attorney, service of a copy should be made upon the attorney and if a party is represented by the Office of the Attorney General, service of a copy should be made upon that office), and on the County Attorney of the County in which the papers from the lower court were filed and any Attorney for the Child. If service of the motion papers is done by personal delivery, the motion should be made returnable on a Monday at least eight (8) days after such service. If service of the motion papers is done by mail, the motion should be made returnable on a Monday at least thirteen (13) days after the motion papers are mailed.

3)As soon as possible after service of copies of the motion papers, the original motion papers, as well as proof that you have served the motion papers on the other parties, the County Attorney and the Attorney for the Child, should be forwarded to this office. If the motion is being made in connection with an appeal to this Court, you should also attach to the motion papers a copy of the order or judgment being appealed from, the decision, if any, upon which the order or judgment was based, and a copy of the notice of appeal.

4)THERE WILL NOT BE ORAL ARGUMENT ON THE RETURN DATE OF THE MOTION.

Revised:

February 19, 2014

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Please fill in the underlined spaces in the follow ing form. Return the original to this Court, forward one copy to each of your adversaries, forward one copy to the County Attorney, one copy to the Attorney for the Child and keep one for your records.

PLEASE TAKE NOTICE that, upon the annexed affidavit sworn to on the					day of
, 20			, a motion will be made to this court, on the		day of

,20 , in the City of Albany New York, for an order

granting the appellant permission to appeal as a poor person.

Dated:

(Signature)

(Print Name)

(Address)

(Your name, address and telephone number)

DIN # (if applicable)

(Telephone)

PLEASE TAKE NOTICE that, pursuant to section 800.2 (a) of the Rules of this Court, this motion will be submitted on the papers, and the personal appearance of counsel or the parties is neither required nor permitted.

Revised:

February 19, 2014

2

AFFIDAVIT IN SUPPORT OF MOTION

STATE OF NEW YORK

COUNTY OF		ss.:

, being duly sworn, deposes and says

that I make this affidavit in support of my application for poor person status and assignment of counsel.

1.My full name and date of birth is:

2.What is the nature of the above entitled proceeding?

3.	I am appealing from a judgment/order of		Court,		County,

which provides as follows:

(Please attach hereto a copy of the order or judgment appealed from, the decision, if any, upon which the order or judgment is based, and a copy of your notice of appeal.)

4.	a.	An order or judgment has been entered in the							Court Clerk’s
	Office on			, 20		.
	b.	A copy of that		order or judgment was served on me on					, 20		.

c.Have you filed an original and two copies of any notice of appeal with the Clerk of the

appropriate court?		Yes		No
If yes, when?

d.If yes, have you served a copy of the notice of appeal on your adversaries and the

attorney for the child?		Yes		No
If yes, when?
e.	Were you represented by counsel?				Yes	No
	Counsel's name and address:
	(if applicable)

Revised:

February 19, 2014

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f.	Was counsel assigned or retained?	Assigned		Retained

5.If you were represented by retained counsel in the court below, state the name and address of the person who paid his/her fee and the amount.

6.What relief are you seeking by this motion?

7.What facts are present to support your contention that there is merit to your appeal? (Attach additional documentation, if necessary.)

8.Are you able to pay the costs, fees and expenses necessary to maintain the appeal?

YesNo

9. Are youSingleMarriedSeparatedDivorced

If married, what is the name of your spouse?

What are the first names and ages of your children?

Revised:

February 19, 2014

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10.What is your occupation? If you are a student, indicate the school which you attend and the name and address of the person who is paying your tuition, room and board.

11. Are you are employed?	Yes		No		If yes, please state your weekly salary and

provide the name and address of your employer. Please provide a copy of your most recent pay

stub.

12.If married and your spouse is employed, what is his/her weekly gross salary and the name and address of his/her employer?

13. Do you receive support from anyone? Yes		No		If yes please provide the name,

relationship, address and the amount of support provided to you.

Revised:

February 19, 2014

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14. Do you support anyone? Yes			No			If yes, please provide the name, relationship,
address and the amount of support you provide.

15. Do you own real estate either by yourself or with someone else? Yes		No
If yes please provide the following information:

a.Other owner(s) (if any):

b.Location (street address, mailing address; Town, County, State):

c.Current value, including improvements:

d.Existing mortgages and/or liens (Attach additional sheet if required):

1.Name of bank, mortgagee or lien holder:

2.Balance due:

16.List the location and amount of any savings or checking accounts held in your name or jointly with others (Attach additional sheet if required):

Location (Bank)		Type		Owners		Balance

Revised:

February 19, 2014

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17.List any stocks, bonds, trusts or cash on hand owned by you in which you have any benefit and give the type, location and value of each (Attach additional sheet if required):

18.Please state the year, make model and value of any motor vehicle(s) owned by you and the amount of any existing loan(s):

19. Do you own any other assets not listed above? Yes		No

20.If yes please describe the assets(s) and state the value (Attach additional sheet if required):

21.My monthly income and expenses are as follows:

INCOME: My salary

My spouse's earnings Other income

TOTAL

EXPENSES:

Rent or mortgage payment

Food

Utilities (heat, telephone, water, electric, cable)

Automobile expenses

Premiums on life or medical insurance policies

Repayment of loans

Name of creditor and amount

Other obligations, including alimony /support

TOTAL

Revised:

February 19, 2014

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22. Is any other person beneficially interested in any recovery sought herein?					Yes		No
If so, is such person able to pay the costs, fees and expenses of maintaining the appeal?
Yes		No

23.Do you authorize the Court to make any inquiries or investigation concerning the answers given

to you in this affidavit?	Yes		No

24.Did someone else complete this form on your behalf?

Yes No

25.If "yes" to question 24, were the questions and answers read to you and are your

answers true?	Yes		No

(Signature) (Print Name)

Sworn to before me this
day of		,		.
	Notary Public

Revised:

February 19, 2014

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		AFFIDAVIT OF SERVICE OF MAILING
STATE OF NEW YORK		)
COUNTY OF			) ss.:

, being duly sworn, deposes and says:

On the		day of	, 20			, I served a true copy of the

annexed notice of motion and supporting affidavit by mailing the same in a sealed envelope, with

postage prepaid thereon, in a post office or official depository of the U.S. Postal Service within the

State of New York, addressed to the last known addressee(s) as indicated below:

(Insert here the name[s] and address[es] of the person[s] to w hom you are mailing the papers being filed with this Court. If necessary, attach extra pages for additional nam es and addresses.)

(Signature)

(Print Name)

Sworn to before me this

day of	,	.

Notary Public

Revised: February 19, 2014

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