Constitution Rights Org Edu

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A-5. VERIFICATION OF PETITION

VERIFICATION195
STATE OF NEW YORK )
COUNTY OF 196 ss.: )

,197 being duly sworn, deposes and says that deponent is the petitioner in the above-
encaptioned proceeding, that [he/she] has read the foregoing petition and knows the contents thereof, that the
same is true to deponent's own knowledge, except as to matters therein stated upon information and belief,
which matters deponent believes to be true.
198

Sworn to before me this
__th day of , 20__
NOTARY PUBLIC 199

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-6. REQUEST FOR JUDICIAL INTERVENTION


REQUEST FOR JUDICIAL INTERVENTION
Index No. 200
Supreme Court 201 County
Date Purchased
PLAINTIFF(S):202
IAS entry date:
Judge Assigned:
DEFENDANTS(S):203
RJI Date:
———————————————————————————————————————-
NATURE OF JUDICIAL INTERVENTION:
[]204 Order to Show Cause
(Clerk enter return date )205
[]206 Notice of Petition (return )207
NATURE OF ACTION OR PROCEEDING
SPECIAL PROCEEDINGS
[] Art. 78
Is this proceeding against a:
[Yes/No] Municipality: 208[Yes/No] Public Authority: 209
[Yes/No] Does this proceeding seek equitable relief?210
[Yes/No] Does this proceeding seek recovery for personal injury?211
[Yes/No] Does this proceeding seek recovery for property damage?212
Estimated time period for case to be ready for trial: 0-12 months
Attorney for Plaintiff(s):
Name213 Address Phone
Attorney for Defendant(s):
Name214 Address Phone
RELATED CASES:
Title215 Index Number Court Nature of Relationship

I affirm under penalty of perjury that, to my knowledge, other than as noted above, there are and have
been no related actions or proceedings, nor has a request for judicial intervention previously been filed in this
proceeding.
Dated: ____________ 216
_________________________________
(Signature)
_____________________________________
(Print Name)

Date ____________________________


..............................................

200. The court will fill in this blank.

201. Write the name of the county where you are bringing the action.

202. Write your name.

203. Write the name of the respondents.

204. If you are filing an Order to Show Cause, check this box.

205. If you are filing an Order to Show Cause, write the date you suggest the case be heard.

206. If you are filing a Notice of Petition, check this box.

207. If you are filing a Notice of Petition, write the date you suggest the case be heard.

208. Write "no" unless you are suing a city.

209. Write "yes" if you are suing any public officials or government agencies.

210. Write "yes" if you are seeking to prevent an agency or official from acting in a way which is harmful to you.

211. Write "yes" if you want to recover for injuries suffered by you.

212. Write "yes" if you want to recover for property damage. If not, write "no."

213. Write your name and address.

214. Write the name and address of the respondents.

215. If you have previously brought an Article 78 proceeding that is related to the Article 78 proceeding you are
currently bringing, write the title, index number, court and nature of relationship of that proceeding.

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A-7. APPLICATION FOR AN INDEX NUMBER
INDEX
NUMBER
Application for INDEX NUMBER
Pursuant to section 8018, New York Civil Practice Law & Rules
Title of Action: ARTICLE 78217
[David Smith
v.
William Jones, Commissioner of the Department of Correctional Services]
Name and address of Attorney for Plaintiff or Petitioner Telephone No.218 (PRO SE)
Name and address of Attorney for Defendant or Respondent Telephone No.219

A. Nature of Special Proceeding Article 78 Proceeding
B. Application for Index Number filed by: Plaintiff Defendant
C. Was a previous Third Party Action filed? Yes No
COMPLETE Do Not Detach THIS STUB
Supreme Court, 220 County
221
v.
222 INDEX NUMBER:223
217. Write the name of your action.
218. Write your name and address.
219. Write the name and address of the respondent.
220. Write the name of the county in which you are bringing the action.
221. Write your name as the petitioner.
222. Write the name and official title of the respondent or respondents.
223. Leave this blank. Do not write a number.

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704 A JAILHOUSE LAWYER'S MANUAL Ch. 22
A-8. AFFIDAVIT IN SUPPORT OF REQUEST FOR REDUCTION/WAIVER OF FEEES

704 A JAILHOUSE LAWYER'S MANUAL Ch. 22
A-8. AFFIDAVIT IN SUPPORT OF REQUEST FOR REDUCTION/WAIVER OF FEES
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF
X
In the Matter of the Application of :
: Affidavit in Support of 
, : Application for Fee
: Reduction/Waiver Pursuant to
: N.Y. C.P.L.R. 1101(f)
- against - :
: Index No

For a Judgment Pursuant to Article 78 :
of the Civil Practice Law and Rules


704 A JAILHOUSE LAWYER'S MANUAL Ch. 22
A-8. AFFIDAVIT IN SUPPORT OF REQUEST FOR REDUCTION/WAIVER OF FEES
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF
X
In the Matter of the Application of :
: Affidavit in Support of
, : Application for Fee
Petitioner, : Reduction/Waiver Pursuant to
: N.Y. C.P.L.R. 1101(f)
- against - :
: Index No.
, :
Respondent, :
:
For a Judgment Pursuant to Article 78 :
of the Civil Practice Law and Rules :
X


I, ,224 being duly sworn, hereby declare as follows:

1. I am the petitioner in the above-entitled proceeding, I am an inmate in a state correctional facility
[place of incarceration: ]225, and I submit this affidavit in support of my application for a
reduction of the filing fees pursuant to N.Y. C.P.L.R. 1101(f) (and that an attorney be assigned to represent
me).226

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):

[Value:]. 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 , 20 .______________ 227

NOTARY PUBLIC AUTHORIZATION

I, ,228 inmate number , 229 request and authorize the agency holding me in custody to send to the Clerk of the Court 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.   

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 I MAY HAVE TO PAY THE ENTIRE FEE IF THE COURT DENIES MY REQUEST FOR A FEE REDUCTION. MOREOVER, I UNDERSTAND THAT THE FEE DETERMINED BY THE COURT WILL BE PAID IN INSTALLMENTS BY AUTOMATIC DEDUCTIONS FROM MY CORRECTIONAL FACILITY TRUST FUND ACCOUNT EVEN IF MY CASE IS DISMISSED.230(signature)227.

This is where the notary public notarizes the affidavit224. Your name.225. Name and address of your correctional facility.226. Include this part of the sentence if you would like to request that a lawyer represent

you.Ch. 22 HOW TO CHALLENGE ADMINISTRATIVE DECISIONS USING ARTICLE 78 7054.

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 , 20 .______________ 227

NOTARY PUBLIC AUTHORIZATION I, ,228 inmate number , 229 request and authorize the agency holding me in custody to send to the Clerk of the Court 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. 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 I MAY HAVE TO PAY THE ENTIRE FEE IF THE COURT DENIES MY REQUEST FOR A FEE REDUCTION. MOREOVER, I UNDERSTAND THAT THE FEE DETERMINED BY THE COURT WILL BE PAID IN INSTALLMENTS BY AUTOMATIC DEDUCTIONS FROM MY CORRECTIONAL FACILITY TRUST FUND ACCOUNT EVEN IF MY CASE IS DISMISSED.230(signature)227.

This is where the notary public notarizes the affidavit by signing it and fixing his or her official seal to it. If you have difficulty obtaining the services of a notary public, you should have another prisoner witness your signature. (Use this technique only as a last resort.)

If another prisoner is your witness, you should add at the bottom of the affidavit:I declare that I have not been able to have this [affidavit] notarized according to law because [explain here your efforts to get the affidavit notarized].

I therefore declare under penalty of perjury that all of the statements made in this [affidavit] are true to my own knowledge, and I pray leave of the Court to allow this [affidavit] to be filed without notarization.[Your signature].228. Your name.229. Your inmate number.230.

Your signature. By signing this section, you give permission for your facility to send the Court copies of your trust fund account statement.

You also authorize the facility to withdraw the filing fee from your account and to send it to the Court.

 The entire filing fee will be withdrawn automatically from your account even if your case is dismissed.[/list]

X. DISCLOSURE

A. Discovery is presumptively improper in an article 78 proceeding.

Except for a request for admission pursuant to CPLR 3123, disclosure is not permitted in an article 78 proceeding without leave of court. CPLR 408.

"[D]isclosure is available only by leave of court in a CPLR article 78 proceeding"
(Stapleton Studios. LLC v. City of N.Y., 7 AD.3d 273, 274-75 (1 st Dep't
2004) (reversing Supreme Court order granting leave to conduct discovery in an article 78

https://casetext.com/case/lutsky-v-shuart

Lutsky v. Shuart
Opinion
April 3, 1973

Leonard S. Clark and Saul R. Fenchel for petitioners.

Joseph Jaspan, County Attorney, for respondents.

ALEXANDER BERMAN, J.

This is a proceeding pursuant to CPLR article 78 seeking judgment directing the respondent to reinstate petitioner's eligibility for full medical assistance as of October 30, 1972, and requiring the respondents to furnish reimbursement for any necessary medical expenses incurred after that date, and further directing respondents to make a  prompt search of their records and provide the same relief for all those recipients of medical assistance whose eligibility was terminated or curtailed as a result of the increase of social security benefits which took place because of the 1972 amendments to the Social Security Act.

Petitioners were receiving both public assistance under the Aid to the Aged, Blind and Disabled program (AABD) and social security insurance benefits.

Because of an increase of social security benefits effected by Public Law 92-336 (U.S. Code Service L.Ed., Aug., 1972, Supp., p. 1346), the respondent Nassau County Department of Social Services changed petitioners' eligibility for full medical assistance (Class A) to that of Class B which requires the payment of 20% of their necessary medical expenses.

On October 30, 1972, Public Law 92-603 was enacted. Section 249E of this statute (U.S. Code Service L.Ed., Dec. 1972, Supp., p. 2823) provides, in effect, that those who were receiving aid and assistance under a Federally approved State plan, and also social security benefits in August of 1972 should not be deemed ineligible for such aid and assistance for any month thereafter prior to October of 1974 because of the increases in social security benefits resulting from the enactment of Public Law 92-336. In an administrative letter dated November 24, 1972, to the local social service departments, the State Department of Social Services indicated that medical assistance should be provided just as if there had been no social security increases.

 This letter further directs that the local social service departments should take action to fully implement this purpose and that such action must be taken immediately.

Despite the Federal law and the clear administrative direction, petitioners' eligibility for full medical assistance was not reinstituted immediately to "Type A" coverage (full medical assistance) until February 2, 1973, more than two months after the directive dated November 24, 1972, which incidentally, was two days after the commencement of this proceeding.

The affidavit of the Commissioner states that "the policy of the Nassau County Department of Social Services has been to restore those who lost `Type A' coverage due to Public Law 92-336 to said `Type A' coverage."

It is significant that this affidavit contains no unequivocal assertion that the directive contained in the letter from the State Department has been fully and promptly complied with, nor are there any details as to exactly what was done to comply.

No reason has been given by the respondents for failing to comply immediately.


This bureaucratic delay of more than two months is inexcusable.

The court is satisfied that such failure to promptly comply with the directive may have caused considerable inconvenience and hardship to these petitioners and others similarly situated.

In view of this failure to fully and promptly comply with the directive of November 24, 1972, the petitioners are entitled to judgment directing the respondents to make a prompt search of their records and to determine the names of those recipients of medical assistance whose eligibility was terminated or curtailed by reason of the 1972 amendments to the Social Security Law, and to furnish them with the benefits to which they were entitled prior thereto.

The respondents are also directed to reimburse those who incurred medical expenses after the date of October 30, 1972, and who make claim thereto and who establish same by competent proof.

The contention of respondents that reimbursement may not be made by reason of section 367-a of the Social Security Law and section 360.17 of title 18 of the official New York State Codes, Rules and Regulations cannot apply in this situation. ( Matter of Cole v. Wyman, 40 A.D.2d 1033; also Matter of Rosenblum v. Lavine, 70 Misc.2d 667, 668.)

The court further holds that the exhaustion of administrative proceedings is not required.

To require those poor, needy individuals to institute separate proceedings to obtain what the State Department of Social Services and the Congress have stated that they are entitled to creates an unnecessary hardship.



Implicit in this decision is the conclusion of the court that this is a proper class action, pursuant to CPLR 1005, in that the issues raised here are of common and general interest to all persons lawfully entitled to "Type A" benefits.

https://codes.findlaw.com/ny/real-property-actions-and-proceedings-law/rpa-sect-753/

Real Property Actions and Proceedings Law -
RPA § 753. Stay in premises occupied for dwelling purposes

4. In the event that such proceeding is based upon a claim that the tenant or lessee has breached a provision of the lease, the court shall grant a thirty day stay of issuance of the warrant, during which time the respondent may correct such breach.

5. Any provision of a lease or other agreement whereby a lessee or tenant waives any provision of this section shall be deemed against public policy and void.