AFFIDAVIT IN SUPPORT OF APPLICATION TO PROCEED AS A POOR PERSON:
Field 1: Insert the county in which this action is brought.
Field 2: Print the Plaintiff's name.
Field 3: Insert the index number.
Field 4: Print the Defendant's name.
Field 5: Insert the county in which the Plaintiff signed this document.
Field 6: Insert the Plaintiff's name.
Field 7: Fill in the address of Plaintiff, the village where the Plaintiff resides and the county where the Plaintiff resides. In addition, indicate the number of years that the Plaintiff resided in New York State.
Field 8: Fill in the appropriate subdivision number and the grounds for divorce as indicated at the end of the form.
Field 9: Plaintiff must list all sources of income including any amounts earned on a weekly, monthly or yearly basis and submit proof. For example, Plaintiff may attach a pay stub, W-2 form or social services identification.
Field 10: Plaintiff must list any property that he or she has and the value of this property. This must include bank accounts and the amounts in those bank accounts.
Field 11: Leave this section unchanged.
Field 12: Leave this section unchanged.
Field 13: Indicate whether prior requests were made for similar relief.
Field 14: Plaintiff must sign this document before a notary public.