Affidavit In Support Of Application To Proceed As A Poor Person - New York Supreme Court Page 4

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WHEREFORE, I respectfully ask for an order permitting me to prosecute this action
as a poor person.
[16. SIGN YOUR NAME BEFORE NOTARY]
[17 PRINT YOUR NAME]
Sworn to before me this
day of
, 20
Notary Public
[18. Affidavit must be notarized]

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