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Affidavit In Support Of Application To Proceed As A Poor Person - New York Supreme Court Page 3

8) I support myself and the following people in whole or in part [13. Identify all

dependents. If a dependent is under the age of 21, you must also put their age. If a

dependent is not living with you but you have a duty to contribute to their support,

you must provide the details of the support.]

9) 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.

10) No other person is beneficially interested in the recovery sought herein.

11) A prior application [14. Check that a prior application has been made only if

you are seeking the same relief again] _____has or ____ has not been made for the

relief requested herein. If a prior application has been made then provide the following

information [15. What Court, when, who made the application, the result of the

application, attach a copies of the application and explain why you are making

another application.]

Affidavit In Support Of Application To Proceed As A Poor Person - New York Supreme Court Page 3