New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle A - JUDICIAL ADMINISTRATION › Chapter I - Standards and Administrative Policies › Subchapter C - Rules Of The Chief Administrator Of The Courts › Part 140 - Civil Actions Or Proceedings Brought By Inmates › Section 140.6 - Appendices

Current through Register Vol. 46, No. 28, July 10,
					 2024
___________ COURT
___________ COUNTY
___________ x
Plaintiff,
Affidavit in Support of Application Pursuant to CPLR 1101
						(Poor Person Status for an Incarcerated Person)
INDEX/FILE#
DIN#
Defendant,
___________ x
State of New York)
(ss: County of ___________)
___________ being duly sworn, says:
1. I am the Plaintiff/Petitioner in the
					 above-captioned action/ proceeding: I am an incarcerated person 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
					 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):
Property: Value:
___________ ___________
5. I am responsible for payment of the
					 following debts:
Debt Amount:
___________
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 abovecaptioned action/proceeding.
____________
(signature)
Sworn to before me this _____ day
of ____, ____
Notary Public
AUTHORIZATION
I, ____________, incarcerated person 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
						abovecaptioned 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
						abovecaptioned 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.
___________
(signature)
(APPENDIX A-2)
_________ COURT
STATE OF NEW YORK
_________ COUNTY
_________ x
Plaintiff,
ORDER Determining Application for Poor Person Status for
						an Incarcerated Person (CPLR 1101)
INDEX/FILE#
DIN#
NYSID#
ORI#
Defendant,
_________ x
Nature of action/proceeding: _________, being a
						federal/state/local incarcerated person 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/ incarcerated person 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/
						incarcerated person can reasonably afford same, the applicant/ incarcerated
						person 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 incarcerated person and reported to the
						superintendent or other public official in charge of the facility where the
						applicant/ incarcerated person is confined, who shall collect such amount from
						the applicant/ incarcerated person 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.
[ ] __________
Date Judge
(APPENDIX A-3)
__________ COURT
STATE OF NEW YORK
__________ COUNTY
__________ x
In the Matter of the Correctional Facility Trust Fund
						Account of ORDER to Rescind Order of Collection of a Civil Filing Fee from an
						Incarcerated Person's Trust Account
INDEX/FILE#
ORI#
__________ x
This Court,
Having issued an order dated ___/___/___:
(1) granting __________, an incarcerated
					 person at __________ (name of Correctional Facility), poor person status in
					 __________ (name of case);
(2)
					 requiring such incarcerated person 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
					 incarcerated person'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 incarcerated
						person 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 incarcerated person'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.
__________
Date Judge