Fill and Sign the Your Guide to Small Claims Ampampamp Commercial Small Claims in Form

State of New York Court of Claims ___________________________________________ ________________________________, ________________________________,Claimant(s) v. Claim ________________________________,________________________________, Defendant(s) ___________________________________________ 1. The post office address of the claimant is ______________________________________________________________________________________________________________. 2. This claim arises from the acts or omissions of the defendant. Details of said acts or omissions are as follows ( be specific) : _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. 3. The place where the act(s) took place is ( be specific): ____________________________________________________________________________________________________________________________________________________________________________________. 4. This claim accrued on the ____ day of ______________, ________. (over) 5. (Check appropriate box ): This Claim is served and filed within 90 days of accrual. OR A Notice of Intention to File a Claim was served on _____________________, which date was within 90 days of accrual. OR This is a claim by a correctional facility inmate to recover damages for injury to or loss of personal property and it is served and filed within 120 days of the exhaustion of claimant’s administrative remedies. By reason of the foregoing, Claimant was damaged in the amount of $______________, and Claimant demands judgment against the Defendant(s) in for said amount. _____________________________________Claimant VERIFICATION STATE OF NEW YORK ) ) ss: COUNTY OF ___________) __________________________________, being duly sworn, deposes and says that deponent is the Claimant in the within action; that deponent has read the foregoing Claim and knows the contents thereof; that the same is true to deponent’s own knowledge, except as to matters therein stated to be alleged upon information and belief, and that as to those matters, deponent believes it to be true. _________________________________________ Sworn to before me this ____ dayof _________________, ______. ___________________________ Notary Public, State of New York SERVICE AND FILING INSTRUCTIONS You must serve a copy of the claim in accordance with Court of Claims Act section 11(a) and you must file the original and two copies, with proof of service and the filing fee of $50.00, or an application for waiver or reduction of the filing fee, with the Clerk of the Court of Claims within 90 days of accrual of the claim (120 days in the case of an inmate claim for loss of or damage to personal property). FAILURE TO EFFECT PROPER AND TIMELY SERVICE AND FILING MAY RESULT IN DISMISSAL OF YOUR CLAIM. New York State Court of ClaimsJustice Building, P.O. Box 7344 Albany, New York 12224 (518) 432-3411 State of New York Court of Claims____________ ______________________________, Claimant, Affidavit in Support of Application Pursuant to CPLR 1101 (d) v. Claim No. The State of New York, ______________________________, Defendant(s). _________________________________ State of New York ) ) ss: County of ______________ ) I, _______________________________, being duly sworn, hereby declare as follows: 1) I am the claimant in the above-entitled proceeding, I am not an inmate in a federal, state or local correctional facility and I submit this affidavit in support of my application for a waiver of the filing fee pursuant to CPLR 1101(d). 2) I currently receive income from the following sources (check appropriate boxes): Salary or wages (state employers name and address and amount of take-home salary or wages: ) ______________________________________________________ Public assistance (amount): ___________________________________________ Social Security / SSI (amount): _________________________________________ Other (source and amount): ___________________________________________ 3) In the past twelve months, I have received money from the following sources: Business, profession or other self-employment yes no Rent payments, interest or dividends yes no Pensions, annuities or life insurance payments yes no Disability or workers’ compensation payments yes no Gifts or inheritances yes no (If your answer to any of the above is “yes,” describe each source of money and state the amount received and what you expect to continue to receive) (over): ________________________________________________________________________ ________________________________________________________________________ 4) (check appropriate box): I do not own any cash or bank accounts. I own cash and bank accounts with a total value of _________________. 5) I own the following property (real estate, bonds, stocks, securities, automobiles or any other property): NONE List property: Value: ____________________________ ___________________ ____________________________ ___________________ ____________________________ ___________________ 6) The following persons are dependent on me for their support (state name of dependent, your relationship and how much you contribute to their support. If none, state “none.”): _______________________________________________________________________ _______________________________________________________________________ 7) I have no savings, property, assets or income other than as set forth herein. 8) I am unable to pay the filing fee necessary to prosecute this proceeding. 9) No other person who is able to pay the filing fee has a beneficial interest in the result of this proceeding. 10) The facts of my case are described in my claim and other papers filed with the court. 11) I have made no prior request for this relief in this case. ________________________________________(signature) Sworn to before me this ___ day of __________, ________.___________________________ Notary Public State of New York Court of Claims____________ ______________________________, Claimant, Affidavit in Support of Application Pursuant to CPLR 1101 (f) v. Claim No. The State of New York, ______________________________, Defendant(s). _________________________________ State of New York ) ) ss: County of ______________ ) I, _______________________________, being duly sworn, hereby declare as follows: 1) I am the claimant in the above-entitled proceeding, I am an inmate in a federal, state or local correctional facility (state place of incarceration: _____________________), and I submit this affidavit in support of my application for a reduction of the filing fee pursuant to CPLR 1101(f). 2) I currently receive income from the following sources, exclusive of correctional facility wages:__________________________________________________________________________________________________________________________ 3) I own the following valuable property (other than miscellaneous personal property): NONE List property: Value: ____________________________ ___________________ ____________________________ ___________________ ____________________________ ___________________ 4) I have no savings, property, assets or income other than as set forth herein. 5) I am unable to pay the filing fee necessary to prosecute this proceeding. 6) No other person who is able to pay the filing fee has a beneficial interest in the result of this proceeding. 7) The facts of my case are described in my claim and other papers filed with the court. 8) I have made no prior request for this relief in this case.________________________________________(signature) Sworn to before me this ___ day of __________, ________. ____________________________ Notary Public AUTHORIZATION I, _______________________, inmate number _____________________, request and authorize the agency holding me in custody to send to the Clerk of the Court of Claims certified copies of the correctional facility trust fund account statement (or the institutional equivalent) for the past six months. I further request and authorize the agency holding me in custody to deduct the filing fee from my correctional facility trust fund account (or the institutional equivalent) and to disburse those amounts as instructed by the Court of Claims. This authorization is furnished in connection with the above entitled case and shall apply to any agency into whose custody I may be transferred. I UNDERSTAND THAT THE ENTIRE FILING FEE AS DETERMINED BY THE COURT OF CLAIMS WILL BE PAID IN INSTALLMENTS BY AUTOMATIC DEDUCTIONS FROM MY CORRECTIONAL FACILITY TRUST FUND ACCOUNT EVEN IF MY CASE IS DISMISSED. __________________________________________(signature) New York State Court of Claims - Filing by Fax Cover Sheet(print form, complete, and fax with paper to be filed) Date: Claim Number (if any): Paper Being Filed: Name and Address of Filing Party or Attorney: Telephone Number of Filing Party or Attorney: Fax Number of Filing Party or Attorney: Total Number of Pages of this Transmission, including Cover Page: ****** FOR CLAIM FILINGS ONLY ****** If you are filing a claim, you must either pay the $50.00 filing fee by completing the credit card authorization, or make an application for a waiver or reduction of the filing fee by submitting the appropriate affidavit. CREDIT CARD AUTHORIZATION I, ____________________________________ , authorize the New York State Court of Claims to charge my credit card for the $50.00 filing fee required for filing the above claim. Master Card Visa _____________________________ ________________________ Cardholder Name Cardholder Signature _____________________________ ___________________________ Credit Card Number Expiration Date FAX to: 877-626-8584 (toll-free)