_______COURT

_______COUNTY

______ x

__________ x

County of_____)

_____being duly sworn, says

1. I am the Plaintiff/Petitioner in the above-captioned action/proceeding: I am an inmate under sentence for conviction of a crime incarcerated in (include name and mailing address) __________________, a federal/state/local correctional facility; and I submit this affidavit in support of my application for poor person status in such action action/proceeding.

2. During the past six months:

□ I was not incarcerated at any other federal/state/local correctional facility.

□ I was incarcerated in the following federal/state/local correctional facilities) (include name(s) and mailing address(es)) in addition to the facility in which I am now incarcerated:

3. I currently receive income from the following sources, exclusive of correctional facility wages:

4. I own the following property (list all real and personal property, including bank accounts and securities in which you have a beneficial interest, other than miscellaneous personal property of nominal value):

5. I am responsible for payment of the following debts:

6. I have no savings, property, assets or income other than as set forth herein.

7. I am unable to pay the costs, fees and expenses necessary to prosecute the above-captioned action/proceeding.

8. There is no other person who has a beneficial interest in the recovery I am seeking in the above-captioned action/proceeding who is able to pay the fees, costs and expenses necessary to its prosecution.

9. The nature of the above-captioned action/proceeding and the facts therein are described in my pleadings and in other papers filed with the court.

10. I have made no prior request for this relief in the above-captioned action/proceeding.

Sworn to before me this ___ day

of ____, __

______________

AUTHORIZATION

I, _______, inmate number ___ request and authorize the agency holding me in custody to send to the Clerk of the Court certifies copies of the correctional facility trust fund account statement (or the institutional equivalent) for the past six months.

In the event my application for poor person status in the above-captioned action/proceeding is granted by the Court, I further request and authorize the agency in which I an incarcerated to deduct the amount of any outstanding obligation reported so such agency by the Court pursuant to CPLR 1101(f)(2) from my correctional facility trust fund account (or institutional equivalent) and to disburse such money as instructed by the Court.

This authorization is furnished in connection with the above-captioned action/proceeding, and shall be valid as to any agency into whose custody I may hereafter be transferred.

I UNDERSTAND THAT THE FULL AMOUNT OF THE OUTSTANDING OBLIGATION REFERRED TO HEREIN WILL BE PAID BY AUTOMATIC DEDUCTION FROM MY CORRECTIONAL FACILITY TRUST FUND ACCOUNT EVEN IF MY CASE IS DISMISSED.

(APPENDIX A-2)

_______COURT

STATE OF NEW YORK

_______COUNTY

______ x

__________ x

Nature of action/proceeding: _________________, being a federal/state/local inmate under sentence for conviction of a crime and having made application pursuant to CPLR 1101 poor person status in the above-captioned action/proceeding.

It is hereby ORDERED that this application is:

□ DENIED, and, as required by section 1101 of the CPLR, all applicable filing fees in the action/proceeding must be paid within 120 days of the date of this order, or else the action/ proceeding shall be deemed dismissed without further order of the Court.

□ GRANTED, and the applicant/inmate is directed to pay a reduced filing fee of $__ dollars and he or she shall be liable for no other fees in the action/proceeding before this Court unless a recovery by judgment or by settlement is had in his or her favor in which event the Court may direct him or her to pay out of the recovery all or part of such fees as are hereby forgiven.

It is further ORDERED:

□ That, the Court having found that the applicant/inmate can reasonably afford same, the applicant/inmate IS REQUIRED to make an initial payment of $__ of the reduced filing fee required hereunder; and that, once such initial payment is fully received by the court, the amount of the difference between such initial payment and the reduced filing fee required hereunder, or $__, shall be assessed as an outstanding obligation of the applicant inmate and reported to the superintendent or other public official in charge of the facility where the applicant/inmate is confined, who shall collect such amount from the applicant/inmate in the same manner as mandatory surcharges are collected pursuant to section 60.35(5) of the Penal Law.

□ That, the Court having found that exceptional circumstances render the applicant/inmate unable to pay any filing fee at this time, the applicant/inmate IS NOT REQUIRED to make any initial payment to the Court of a portion of the reduced filing fee required hereunder; and that the full amount of the filing fee required hereunder, or $__, shall be reported to the superintendent or other public official in charge of the facility where the applicant/inmate is confined, who shall collect such amount from the applicant/inmate in the same manner as mandatory surcharges are collected pursuant to section 60.35(5) of the Penal Law.

□ _________________________

_________________________

_________________________

(APPENDIX A-3)

_______COURT

STATE OF NEW YORK

_______COUNTY

______ x

__________ x

This Court,

Having issued an order dated ---/ ---/ ---: (1) granting _______, an inmate at _______ (name of Correctional Facility), poor person status in ______________ (name of case); (2) requiring such inmate to pay a filing fee in such case in the amount of $__; and (3) directing the Superintendent or other public official in charge of the aforesaid Correctional Facility to collect some or all of such filing fee from the inmate's Correctional Facility Trust Fund Account or institutional equivalent, and

Now having received notice that the Clerk of this Court has received payment of the filing fee in full directly from the inmate or a person or persons acting on his/her behalf,

It is hereby ORDERED that so much of the aforesaid order directing the Superintendent or other public official in charge of the aforesaid Correctional Facility to collect some or all of such filing fee from the inmate's Correctional Facility Trust Fund Account or institutional equivalent is rescinded, and that any funds heretofore withheld from such Account pursuant to the aforesaid order shall be restored to such Account.