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FORM 4

AFFIDAVIT IN SUPPORT OF
WAIVER OF FILING FEE

STATE OF NEW YORK
STATE EDUCATION DEPARTMENT
_____________________________________

In the Matter of (PETITIONER'S NAME),
on behalf of (CHILD'S NAME) from
action of the Board of Education
of the ______________ School
District regarding the denial of
admission on the basis of residency.
_____________________________________

STATE OF NEW YORK:
:ss.
COUNTY OF _______:

 

__________________________________, being duly sworn,

(Name)

deposes and says:

1. I am the petitioner in the within action and submit this affidavit in support of my application for waiver of the filing fee required by 8 NYCRR �275.9(b).

2. Provide statement of residence and dependents:

__________________________________________________________

__________________________________________________________

3. Provide statement of employment, if any, and amount and sources of all income: __________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

 

4. Provide statement of total monthly expenses:

__________________________________________________________

__________________________________________________________

__________________________________________________________

5. List all property held by petitioner, including real estate, personal property and bank accounts, together with the total value of each category: __________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

6. I am unable to pay the costs, fees and expenses necessary to pursue this appeal.

7. No other person is beneficially interested in the outcome of this action.

WHEREFORE, I respectfully request that the Commissioner permit me to pursue this appeal without payment of the filing fee required by 8 NYCRR �275.9(b).

______________________________

 

Subscribed and sworn to

before me this ____ day of

_________________ 20 ____

 

______________________________
(Signature of notary public)