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Affidavit Of Appellant In Support Of Application For Permission To Proceed As Poor Person With Assigned Counsel - New York
| Affidavit Of Appellant In Support Of Application For Permission To Proceed As Poor Person With Assigned Counsel Form. This is a New York form and can be used in Civil 3rd Department Appellate Division Appellate Courts . |
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AFFIDAVIT OF APPELLANT IN SUPPORT OF APPLICATION FOR PERMISSION TO PROCEED AS A POOR PERSON WITH ASSIGNED COUNSEL NOTE: An intentionally false answer to any of the questions in this stateme nt could result in your prosecution for the crime of perjury. , being du ly sworn, d eposes an d says that the answe rs to the questions in this affidavit are true, an d that he/sh e* know s that the inform ation is being furnished for the purpose of enabling the court to determine whether or not he/she* is e ntitled to m aintain an appea l as a poor pe rson with a ssigned co unsel. 1. 2. 3. 4. What is your full name, age and date of birth? What is your home address & phone number? If you were represented by retained counsel in the court b elow, state the name and address of the person w ho paid h is/her* fee an d the am ount? If you have been released on bail, what was the amount of the bail and give the name and address of the person w ho furnishe d the colla teral for your bail bond and the name and add ress of the person who paid the premium on the bond? Are you single, married, separated or divorced? (a) If married, what is the name of your spouse? (b) What are the first names and ages of your children? What is your occupation? If you are e mploy ed, wha t is your we ekly salary and the name and address of your employer? 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? (a) If your spouse is employed, what is her/his* weekly salary and name and address of h er/his* em ployer? (b) If you are no t living with y our spouse or children, what are their addresses and how m uch do y ou contrib ute we ekly to the ir support? 5. 6. 7. 8. 9. * Strike ou t whiche ver is not app licable. 2002 © American LegalNet, Inc. -2- 10. (a) (b) (c) Do you or your spouse have any bank accounts in your individual names or jointly with each other or any other person? Do you hav e any insu rance po licies, stocks, bonds, trust accounts or any other investments in your name, or jointly in your name and any other person? If your answ er to either (a) or (b) of this question was "Yes", describe the asset, the location and amount in any bank account and the value of any other asset. 11. If you or yo ur spouse o wn au tomob iles, what is the year and mode l, monthly paym ents if financed, to whom are payments made and what are the number of remaining payments? 12. 13. Do you own your own home or do you rent? What is the approxim ate market value, present mortgage balance, name of bank or other financing institution and monthly payments on any home owned by you in your own name, your spouse's name or jointly with your spouse or any other person? 14. 15. Do you hav e any oth er assets not co vered by the prece ding que stions in this statement? My M onthly inc ome a nd expe nses are as follo ws: INCOME My Sa lary.............................................. My spo use's earnin gs................................ Other income of mine or any member of my im media te family........................... TOTA L INC OME ................................... EXPENSES Rent or m ortgage p ayme nt......................... Food.................................................... Utilities (Hea t, Telepho ne, W ater, Electric)..... Autom obile exp ense................................. Premiums on Life or Medical Insurance p olicies............................... 2002 © American LegalNet, Inc. -3- Repa ymen t of loans.................................. Name of Creditor and amou nt..................... ..................... ..................... ...... ............... ..................... TOTA L EXP ENSE S........................ 15. 16. Do you authorize the Court to make any inquiries or investigation concerning the answers given to you in this affidavit? If the answ ers in this questionn aire are not in your handwriting, were the questions and answers read to you and are your answers true? Your Sign ature (PRINT name, address & phone #) Swor n to befor e me this , . of day Notary Public Form Revised 3/2/98 2002 © American LegalNet, Inc.
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