Affidavit In Support Of Application To Proceed As A Poor Person - New York Supreme Court Page 5
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7[Fill in the spaces next to the instructions. Other spaces are for Court use.]
At a(an) lAS/Special Term Part __
of the Supreme Court of the State
of New York, held in and for the
County
of
Nassau,
at
the
Courthouse thereof, located at
100 Supreme Court Drive, Mineola,
New York on the __ day of
20______
PRESENT: HON.______________________________
Justice of the Supreme Court
----------------------------------------------------------------------------x
In the Matter of the Application of
[19. Index No. & Year]
,
Index No.
[20. Fill in name(s)]
Plaintiff(s)
/
For permission to Prosecute as a Poor Person an
POOR PERSON ORDER
Action pursuant to Article 11 of the CPLR
-against-
,
[21. Fill in name(s)]
Defendant(s)
-----------------------------------------------------------------------------x
Upon the annexed affidavit of [22. Your name]
,
plaintiff sworn to on [23. Date the Affidavit notarized]
and upon
[24. Check one]
Summons and Complaint
Notice of Petition & Petition
Summons with Notice
Affidavit
Other
And it being alleged that [25. Your name]
has
a good cause of action or claim based upon [26. Explain your type of case]
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