Application For Poor Person Status And Assignment Of Counsel In A Criminal Appeal

DIRECTIONS: Failure to properly complete this application may result in its denial. Provide all requested information by completely filling in all blank spaces. You must sign your name on page 4 before a Notary Public. File the original application with this Court together with proof of service of a copy of the application upon the appropriate District Attorney. The proof of service, located on page 5, must also be signed before a Notary Public. Keep one copy of the application for your records. Applications are treated as motions and made returnable on a Monday after proper service upon the District Attorney. Note: A timely filed notice of appeal is required for this application to be considered. SUPREME COURT THIRD DEPARTMENT STATE OF NEW YORK APPELLATE DIVISION THE PEOPLE OF THE STATE OF NEW YORK, Respondent, v APPLICATION FOR POOR PERSON STATUS AND ASSIGNMENT OF COUNSEL , Appellant. Indictment/SCI No.: Please take notice that application will be made to this Court, at the next available motion day of said Court, in the City of Albany, New York, for an order granting poor person status and assignment of counsel. AFFIDAVIT IN SUPPORT OF MOTION STATE OF NEW YORK COUNTY OF ss.: , being duly sworn, deposes and says that I am the appellant and I make this affidavit in support of my application for poor person status and assignment of counsel. 1. My date of birth is: 2. My address is: 3. My DIN # is (if assigned): Revised: February 19, 2014 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. I am appealing from a judgment of conviction and resulting sentence or resentence, having been convicted after a trial a. or after a plea of guilty (Check only one.) I was convicted of the following crimes: b. c. d. e. f. I was convicted in the following county: I was sentenced on: I was represented by attorney: Was that attorney assigned by the trial court? Yes No If your attorney was not assigned, please state the amount of the fee paid and who paid the fee? 5. If you are not appealing from a judgment of conviction and sentence or resentence, please state what you are appealing? 6. Were you released on bail after being sentenced? Yes No If "yes" please state the amount and give the name of the person who provided the money or collateral and who paid the premium on the bond. 7. 8. I am single: married: Yes separated: No divorced: Do you receive support from anyone? If "yes" please provide the name, relationship, address, and amount of support provided to you. 9. Are you employed? Yes No If "yes" please state your weekly salary and provide the name and address of your employer. Please provide a copy of your most recent pay stub. 10. Do you support anyone? Yes No If "yes" please provide the name, relationship, address, and the amount of support you provide. Revised: February 19, 2014 2 American LegalNet, Inc. www.FormsWorkFlow.com 11. Do you own real estate either by yourself or with someone else? If "yes" please provide the following information: a. b Other owner(s) (if any): Location (street address; mailing address; Town; County; State): Yes No c. d. Current value, including improvements: Existing mortgages and/or liens (Attach additional sheet if required): i Name of bank, mortgagee, or lien holder: ii 12. Balance due: List the location and amount of any savings or checking accounts in your name or jointly with others (Attach additional sheet if required): Location (Bank) Type Owners Balance 13. List any stocks, bonds, trusts or cash on hand owned by you or in which you have any benefit and give the type, location and value of each (Attach additional sheet if required): 14. Please state the year, make, model and value of any motor vehicle(s) owned by you and the amount of any existing loan(s): 15. 16. Do you own any other assets not listed above? Yes No If "yes", please describe the asset and state its value (Attach additional sheet if required): Revised: February 19, 2014 3 American LegalNet, Inc. www.FormsWorkFlow.com 17. My monthly income and expenses are as follows: INCOME: My salary or wages My spouse's salary or wages Other income TOTAL EXPENSES: Rent or mortgage payment Food Utilities (heat, telephone, water, electric, cable) Automobile expenses Premiums on life or medical insurance policies Repayment of loans Name of creditor and amount Other obligations, including alimony and/or support TOTAL 18. Do you authorize the Court to make any inquiries or investigation concerning the answers given by you in this affidavit? 19. Did someone else complete this form on your behalf? Yes 20. No Yes No If "yes" to question 19, were the questions and answers read to you and are your answers true? Yes (Signature) (Print Name) DIN No Sworn to before me this day of , 20 . Notary Public Revised: February 19, 2014 4 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF SERVICE OF MAILING STATE OF NEW YORK COUNTY OF ) ) ss.: , being duly sworn, deposes and says: On the day of , 20 , I served a true copy of the annexed application by mailing the same in a sealed envelope, with postage prepaid thereon, in a post office or official depository of the U.S. Postal Service within the State of New York, addressed to the last known addressee(s) as indicated below: (Insert here the name[s] and address[es] of the person[s] to whom you are mailing the papers being filed with this Court. If necessary, attach extra pages for additional names and addresses.) Name & Address Name & Address (Signature) (Print Name) Sworn to before me this day of , 20 . Notary Public Revised: February 19, 2014 5 American LegalNet, Inc. www.FormsWorkFlow.com